MEDICARE: MADISON VILLAGE MANOR, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	4310178	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154504983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADISON VILLAGE MANOR, INC

Provider Business Mailing Address
First Line	:	PO BOX 272
Second Line	:	731 LAKE STREET
City	:	MADISON
State	:	OH
Zip	:	44057-0272
Country	:	US
Telephone Number	:	440-428-1519
Fax Number	:	440-428-6360

Provider Business Practice Location Address
First Line	:	731 N LAKE ST
Second Line	:
City	:	MADISON
State	:	OH
Zip	:	44057-3152
Country	:	US
Telephone Number	:	440-428-1519
Fax Number	:	440-428-6360

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. ANTHONY MICHAEL SERRA
Credential	:	NHA
Telephone Number	:	440-428-1519

Provider Enumeration Date	:	12/15/2007
Last Update Date	:	12/15/2007

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