Provider Demographics
NPI:1174671952
Name:MADISON CENTER, INC.
Entity Type:Organization
Organization Name:MADISON CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLANTON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:574-283-1107
Mailing Address - Street 1:403 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2322
Mailing Address - Country:US
Mailing Address - Phone:574-234-0061
Mailing Address - Fax:574-283-1209
Practice Address - Street 1:403 E MADISON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2322
Practice Address - Country:US
Practice Address - Phone:574-234-0061
Practice Address - Fax:574-283-1209
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADISON CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-08
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN406-14-PIP261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100451660AMedicaid