Healthcare Provider Details

I. General information

NPI: 1154718641
Provider Name (Legal Business Name): MADISON FACILITY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6020 INDIANA AVE
NEW PORT RICHEY FL
34653-3214
US

IV. Provider business mailing address

4302 HOLLYWOOD BLVD #369
HOLLYWOOD FL
33021-6635
US

V. Phone/Fax

Practice location:
  • Phone: 727-843-0600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1473096
License Number StateFL

VIII. Authorized Official

Name: MR. MICHAEL BLEICH
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 845-641-8314