Basic Information
| Provider Information | |||||||||
| NPI: | 1467780510 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MADISON RESIDENTIAL CARE FACILITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MADISON HEALTH AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2821 W DIXON RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722064256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018884080 | ||||||||
| FaxNumber: | 5014869119 | ||||||||
| Practice Location | |||||||||
| Address1: | 2821 W DIXON RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722064256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018884080 | ||||||||
| FaxNumber: | 5014869119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2009 | ||||||||
| LastUpdateDate: | 12/01/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NIKSEFAT | ||||||||
| AuthorizedOfficialFirstName: | SY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5018884080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320700000X | 041 | AR | Y | Residential Treatment Facilities | Residential Treatment Facility, Physical Disabilities |
No ID Information.