{
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"EIN": null,
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"IsOrgSubpart": "Y",
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"OrgName": "MADISON VILLAGE MANOR, INC",
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"NamePrefix": null,
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"FirstLineMailingAddress": "PO BOX 272",
"SecondLineMailingAddress": "731 LAKE STREET",
"MailingAddressCityName": "MADISON",
"MailingAddressStateName": "OH",
"MailingAddressPostalCode": "44057-0272",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "440-428-1519",
"MailingAddressFaxNumber": "440-428-6360",
"FirstLinePracticeLocationAddress": "731 N LAKE ST",
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"PracticeLocationAddressCityName": "MADISON",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "440-428-1519",
"PracticeLocationAddressFaxNumber": "440-428-6360",
"EnumerationDate": "12/15/2007",
"LastUpdateDate": "12/15/2007",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SERRA",
"AuthorizedOfficialFirstName": "ANTHONY",
"AuthorizedOfficialMiddleName": "MICHAEL",
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"AuthorizedOfficialCredential": "NHA",
"AuthorizedOfficialTelephoneNumber": "440-428-1519",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "320600000X",
"TaxonomyName": "Intellectual and/or Developmental Disabilities Residential Treatment Facility",
"LicenseNumber": "4310178",
"LicenseNumberStateCode": "OH",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}