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General NPI Number Information
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NPI Number | 1124148457
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Entity Type | Organization
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Legal Business Name | THE MADERA CORP
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Dates
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Enumeration Date | 03/30/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1704 NORTH BRADFORD ST
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City | GILMER
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State | TX
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Zip | 75644
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Country | US
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Telephone | 903-843-7601
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Fax | 903-843-4871
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Provider Business Mailing Address
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Address Line | 1704 NORTH BRADFORD ST
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City | GILMER
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State | TX
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Zip | 75644
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Country | US
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Telephone | 903-843-7601
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Fax | 903-843-4871
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Authorized Official
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Title or Position | VICE PRES SEC TREASURY
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Name | MRS. GLORIA JEANE MADERA
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Credential | LICENSED VOCATIONAL
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Telephone | 903-843-7601
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 113958
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License Number State | TX
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