Provider Demographics
NPI:1427285147
Name:MADELEINE VILLAGE, LLC
Entity type:Organization
Organization Name:MADELEINE VILLAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIVIANE
Authorized Official - Middle Name:LATESTERE
Authorized Official - Last Name:LEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-965-7937
Mailing Address - Street 1:415 PISGAH CHURCH RD
Mailing Address - Street 2:STE 164
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-2590
Mailing Address - Country:US
Mailing Address - Phone:336-965-7937
Mailing Address - Fax:336-458-2012
Practice Address - Street 1:1476 RANKIN MILL RD
Practice Address - Street 2:
Practice Address - City:MC LEANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27301-9504
Practice Address - Country:US
Practice Address - Phone:336-617-3356
Practice Address - Fax:336-458-2012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-20
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-914320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities