Provider Demographics
NPI:1750855847
Name:MADONNA HOME
Entity Type:Organization
Organization Name:MADONNA HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-435-7809
Mailing Address - Street 1:814 W 37TH ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-2610
Mailing Address - Country:US
Mailing Address - Phone:757-623-6662
Mailing Address - Fax:757-623-4966
Practice Address - Street 1:814 W 37TH ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508-2610
Practice Address - Country:US
Practice Address - Phone:757-623-6662
Practice Address - Fax:757-623-4966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Single Specialty