MEDICARE: MADISON CARE CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033190400
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADISON CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	1391 E MADISON AVE
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92021-8568
Country	:	US
Telephone Number	:	619-444-1107
Fax Number	:	619-444-1403

Provider Business Practice Location Address
First Line	:	1391 E MADISON AVE
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92021-8568
Country	:	US
Telephone Number	:	619-444-1107
Fax Number	:	619-444-1403

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MISS DIANNE FAYE THIBODEAU
Credential	:
Telephone Number	:	619-444-1107

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	08/22/2020

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