Provider Demographics
NPI:1568457380
Name:MADONNA MANOR, INC.
Entity Type:Organization
Organization Name:MADONNA MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-679-8154
Mailing Address - Street 1:85 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760-1634
Mailing Address - Country:US
Mailing Address - Phone:508-699-2740
Mailing Address - Fax:508-699-0481
Practice Address - Street 1:85 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORTH ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02760-1634
Practice Address - Country:US
Practice Address - Phone:508-699-2740
Practice Address - Fax:508-699-0481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0569314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0918938Medicaid
MA0918938Medicaid