Basic Information
| Provider Information | |||||||||
| NPI: | 1962498105 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MADISON HEALTH INVESTORS, LC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LAKE PARK OF MADISON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 259 SW CAPTAIN BROWN RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323404316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509738277 | ||||||||
| FaxNumber: | 8509734006 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 SW CAPTAIN BROWN RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323404316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509738277 | ||||||||
| FaxNumber: | 8509734006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 03/16/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TREFZGER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8283225535 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF16360961 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 24003 | 01 | FL | STATE FACILITY MDS ID NUM | OTHER | 021192300 | 05 | FL | MEDICAID |