Provider Demographics
NPI:1255549465
Name:MADISON HOUSE
Entity type:Organization
Organization Name:MADISON HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:AVANZADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-793-9872
Mailing Address - Street 1:1802 N MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-1236
Mailing Address - Country:US
Mailing Address - Phone:626-793-9872
Mailing Address - Fax:626-793-9847
Practice Address - Street 1:307 LINDA VISTA AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-1235
Practice Address - Country:US
Practice Address - Phone:626-793-9872
Practice Address - Fax:626-793-9847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-19
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960000799315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities