Provider Demographics
NPI:1043215296
Name:MADONNA MANOR, INC.
Entity Type:Organization
Organization Name:MADONNA MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:567-455-0414
Mailing Address - Street 1:2344 AMSTERDAM RD
Mailing Address - Street 2:
Mailing Address - City:VILLA HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3712
Mailing Address - Country:US
Mailing Address - Phone:859-341-3981
Mailing Address - Fax:859-578-7475
Practice Address - Street 1:2344 AMSTERDAM RD
Practice Address - Street 2:
Practice Address - City:VILLA HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3712
Practice Address - Country:US
Practice Address - Phone:859-341-3981
Practice Address - Fax:859-578-7475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100268314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12500567Medicaid
KY12500567Medicaid