Provider Demographics
NPI:1790850915
Name:MADRID HOME FOR THE AGING
Entity Type:Organization
Organization Name:MADRID HOME FOR THE AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:J
Authorized Official - Last Name:KUDEJ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-795-3007
Mailing Address - Street 1:613 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MADRID
Mailing Address - State:IA
Mailing Address - Zip Code:50156-1023
Mailing Address - Country:US
Mailing Address - Phone:515-795-3007
Mailing Address - Fax:515-795-2138
Practice Address - Street 1:613 W NORTH ST
Practice Address - Street 2:
Practice Address - City:MADRID
Practice Address - State:IA
Practice Address - Zip Code:50156-1023
Practice Address - Country:US
Practice Address - Phone:515-795-3007
Practice Address - Fax:515-795-2138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0258863Medicaid
IA0258863Medicaid