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General NPI Number Information
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NPI Number | 1154504983
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Entity Type | Organization
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Legal Business Name | MADISON VILLAGE MANOR, INC
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Dates
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Enumeration Date | 12/15/2007
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Last Update Date | 12/15/2007
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Provider Practice Location Address
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Address Line | 731 N LAKE ST
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City | MADISON
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State | OH
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Zip | 44057-3152
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Country | US
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Telephone | 440-428-1519
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Fax | 440-428-6360
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Provider Business Mailing Address
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Address Line | PO BOX 272 731 LAKE STREET
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City | MADISON
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State | OH
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Zip | 44057-0272
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Country | US
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Telephone | 440-428-1519
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Fax | 440-428-6360
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. ANTHONY MICHAEL SERRA
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Credential | NHA
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Telephone | 440-428-1519
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 4310178
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License Number State | OH
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