Provider Demographics
NPI:1902178643
Name:MADISON HOUSE ASSISTED LIVING
Entity Type:Organization
Organization Name:MADISON HOUSE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:MIGUEL
Authorized Official - Last Name:PERERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-342-4514
Mailing Address - Street 1:167 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-1367
Mailing Address - Country:US
Mailing Address - Phone:706-342-4514
Mailing Address - Fax:
Practice Address - Street 1:3910 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-3431
Practice Address - Country:US
Practice Address - Phone:706-474-3722
Practice Address - Fax:706-557-0203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA104030011310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility