Provider Demographics
NPI:1033190400
Name:MADISON CARE CENTER, LLC
Entity Type:Organization
Organization Name:MADISON CARE CENTER, LLC
Other - Org Name:MADISON CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:THIBODEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-444-1107
Mailing Address - Street 1:1391 E MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-8568
Mailing Address - Country:US
Mailing Address - Phone:619-444-1107
Mailing Address - Fax:619-444-1403
Practice Address - Street 1:1391 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-8568
Practice Address - Country:US
Practice Address - Phone:619-444-1107
Practice Address - Fax:619-444-1403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05064HMedicaid
CA05-5064Medicare ID - Type Unspecified