MEDICARE: MADISON HOUSE

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	315P00000X	Intellectual Disabilities Intermediate Care Facility	960000799	CA

General Provider Information

NPI Number	:	1255549465
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADISON HOUSE

Provider Business Mailing Address
First Line	:	1802 N MADISON AVE
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-1236
Country	:	US
Telephone Number	:	626-793-9872
Fax Number	:	626-793-9847

Provider Business Practice Location Address
First Line	:	307 LINDA VISTA AVE
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91105-1235
Country	:	US
Telephone Number	:	626-793-9872
Fax Number	:	626-793-9847

Authorized Official
Title or Position	:	LICENSEE
Name	:	EDITH AVANZADO
Credential	:
Telephone Number	:	626-793-9872

Provider Enumeration Date	:	05/19/2007
Last Update Date	:	08/13/2008

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Directions to “MADISON HOUSE ” Practice Location

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