Provider Demographics
NPI:1962498105
Name:MADISON HEALTH INVESTORS, LC
Entity Type:Organization
Organization Name:MADISON HEALTH INVESTORS, LC
Other - Org Name:LAKE PARK OF MADISON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:TREFZGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:828-322-5535
Mailing Address - Street 1:259 SW CAPTAIN BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-4316
Mailing Address - Country:US
Mailing Address - Phone:850-973-8277
Mailing Address - Fax:850-973-4006
Practice Address - Street 1:259 SW CAPTAIN BROWN RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-4316
Practice Address - Country:US
Practice Address - Phone:850-973-8277
Practice Address - Fax:850-973-4006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF16360961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24003OtherSTATE FACILITY MDS ID NUM
FL021192300Medicaid
FL021192300Medicaid