Provider Demographics
NPI:1740745447
Name:MADONNA COMPANY
Entity Type:Organization
Organization Name:MADONNA COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REP
Authorized Official - Prefix:MR
Authorized Official - First Name:G
Authorized Official - Middle Name:ANDERSON
Authorized Official - Last Name:S
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:747-256-4015
Mailing Address - Street 1:506 N SPRING ST
Mailing Address - Street 2:#1330
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012
Mailing Address - Country:US
Mailing Address - Phone:747-256-4015
Mailing Address - Fax:
Practice Address - Street 1:13746 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-6716
Practice Address - Country:US
Practice Address - Phone:747-256-4015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty