Provider Demographics
NPI:1154504983
Name:MADISON VILLAGE MANOR, INC
Entity Type:Organization
Organization Name:MADISON VILLAGE MANOR, INC
Other - Org Name:THE GABLES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SERRA
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:440-428-1519
Mailing Address - Street 1:PO BOX 272
Mailing Address - Street 2:731 LAKE STREET
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-0272
Mailing Address - Country:US
Mailing Address - Phone:440-428-1519
Mailing Address - Fax:440-428-6360
Practice Address - Street 1:731 N LAKE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-3152
Practice Address - Country:US
Practice Address - Phone:440-428-1519
Practice Address - Fax:440-428-6360
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADISON VILLAGE MANOR, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-15
Last Update Date:2007-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4310178320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1724665Medicaid