MEDICARE: MADEA HOUSE 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	174200000X	Meals Provider	1235576323	NV
2	251B00000X	Case Management Agency	1235576323	NV

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750811840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADEA HOUSE LLC

Provider Business Mailing Address
First Line	:	903 ROYALMILE WAY
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-9001
Country	:	US
Telephone Number	:	702-488-1472
Fax Number	:	702-816-2990

Provider Business Practice Location Address
First Line	:	903 ROYALMILE WAY
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-9001
Country	:	US
Telephone Number	:	702-488-1472
Fax Number	:	702-816-2990

Authorized Official
Title or Position	:	MEMBER
Name	:	ANDRE HUGHES
Credential	:
Telephone Number	:	702-505-0330

Provider Enumeration Date	:	06/13/2017
Last Update Date	:	07/21/2022

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Directions to “MADEA HOUSE LLC ” Practice Location

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