=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962575811
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MADELIA HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2006
-----------------------------------------------------
Last Update Date | 04/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 DREW AVENUE SE
-----------------------------------------------------
City | MADELIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56062-1841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-642-3255
-----------------------------------------------------
Fax | 507-642-8516
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 DREW AVENUE SE
-----------------------------------------------------
City | MADELIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56062-1841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-642-3255
-----------------------------------------------------
Fax | 507-642-8516
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REVENUE CYCLE MANAGER
-----------------------------------------------------
Name | PRUDENCE TETZLOFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 507-642-3255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 351876
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------