Healthcare Provider Details

I. General information

NPI: 1750811840
Provider Name (Legal Business Name): MADEA HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 ROYALMILE WAY
NORTH LAS VEGAS NV
89032-9001
US

IV. Provider business mailing address

903 ROYALMILE WAY
NORTH LAS VEGAS NV
89032-9001
US

V. Phone/Fax

Practice location:
  • Phone: 702-488-1472
  • Fax: 702-816-2990
Mailing address:
  • Phone: 702-488-1472
  • Fax: 702-816-2990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number1235576323
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number1235576323
License Number StateNV

VIII. Authorized Official

Name: ANDRE HUGHES
Title or Position: MEMBER
Credential:
Phone: 702-505-0330