Healthcare Provider Details

I. General information

NPI: 1053658872
Provider Name (Legal Business Name): MADONNA MANOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2013
Last Update Date: 01/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2344 AMSTERDAM RD
VILLA HILLS KY
41017-3712
US

IV. Provider business mailing address

2344 AMSTERDAM RD
VILLA HILLS KY
41017-3712
US

V. Phone/Fax

Practice location:
  • Phone: 859-426-6400
  • Fax: 859-578-7472
Mailing address:
  • Phone: 859-426-6400
  • Fax: 859-578-7472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number185241
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateKY

VIII. Authorized Official

Name: MARK MULLAHY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 859-426-6400