Provider Demographics
NPI:1467780510
Name:MADISON RESIDENTIAL CARE FACILITY
Entity Type:Organization
Organization Name:MADISON RESIDENTIAL CARE FACILITY
Other - Org Name:MADISON HEALTH AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SY
Authorized Official - Middle Name:
Authorized Official - Last Name:NIKSEFAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-888-4080
Mailing Address - Street 1:2821 W DIXON RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72206-4256
Mailing Address - Country:US
Mailing Address - Phone:501-888-4080
Mailing Address - Fax:501-486-9119
Practice Address - Street 1:2821 W DIXON RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72206-4256
Practice Address - Country:US
Practice Address - Phone:501-888-4080
Practice Address - Fax:501-486-9119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-01
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR041320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities