MEDICARE: MADONNA HOME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376G00000X	Nursing Home Administrator

General Provider Information

NPI Number	:	1750855847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADONNA HOME

Provider Business Mailing Address
First Line	:	814 W 37TH ST
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23508-2610
Country	:	US
Telephone Number	:	757-623-6662
Fax Number	:	757-623-4966

Provider Business Practice Location Address
First Line	:	814 W 37TH ST
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23508-2610
Country	:	US
Telephone Number	:	757-623-6662
Fax Number	:	757-623-4966

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. CHARLENE DAVIS
Credential	:
Telephone Number	:	757-435-7809

Provider Enumeration Date	:	01/11/2019
Last Update Date	:	01/11/2019

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Directions to “MADONNA HOME ” Practice Location

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