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General NPI Number Information
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NPI Number | 1750080578
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Entity Type | Organization
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Legal Business Name | MADELYN AND MANOR
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Dates
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Enumeration Date | 03/01/2023
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Last Update Date | 03/01/2023
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Provider Practice Location Address
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Address Line | 202 N CEDAR AVE STE 1
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City | OWATONNA
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State | MN
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Zip | 55060-2306
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Country | US
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Telephone | 310-739-1601
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Fax |
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Provider Business Mailing Address
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Address Line | 202 N CEDAR AVE STE 1
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City | OWATONNA
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State | MN
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Zip | 55060-2306
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DOUGLAS GREEN JR.
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Credential |
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Telephone | 310-739-1601
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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