1366516239 NPI number — MADRID HOME FOR THE AGING

Table of content: (NPI 1366516239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366516239 NPI number — MADRID HOME FOR THE AGING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MADRID HOME FOR THE AGING
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE CEDARS OF OF MADRID HOMES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366516239
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 N KENNEDY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADRID
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50156-7608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-795-4097
Provider Business Mailing Address Fax Number:
515-795-4286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 N KENNEDY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADRID
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50156-7608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-795-4097
Provider Business Practice Location Address Fax Number:
515-795-4286
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HANSEN
Authorized Official First Name:
KRIS
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
515-795-3007

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  S0176 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0298943 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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