MEDICARE: MADONNA MANOR, INC.

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	100268	KY

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	:	1043215296
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADONNA MANOR, INC.

Provider Business Mailing Address
First Line	:	2344 AMSTERDAM RD
Second Line	:
City	:	VILLA HILLS
State	:	KY
Zip	:	41017-3712
Country	:	US
Telephone Number	:	859-341-3981
Fax Number	:	859-578-7475

Provider Business Practice Location Address
First Line	:	2344 AMSTERDAM RD
Second Line	:
City	:	VILLA HILLS
State	:	KY
Zip	:	41017-3712
Country	:	US
Telephone Number	:	859-341-3981
Fax Number	:	859-578-7475

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MS. WENDY DOLYK
Credential	:
Telephone Number	:	567-455-0414

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	05/01/2017

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Directions to “MADONNA MANOR, INC. ” Practice Location

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