Provider Demographics
NPI:1679967244
Name:ANTONINE VILLAGE
Entity type:Organization
Organization Name:ANTONINE VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:MADELEINE
Authorized Official - Last Name:ISKANDAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-538-9822
Mailing Address - Street 1:2675 N LIPKEY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:44451-9665
Mailing Address - Country:US
Mailing Address - Phone:330-538-9822
Mailing Address - Fax:330-538-9820
Practice Address - Street 1:2675 N LIPKEY RD
Practice Address - Street 2:
Practice Address - City:NORTH JACKSON
Practice Address - State:OH
Practice Address - Zip Code:44451-9665
Practice Address - Country:US
Practice Address - Phone:330-538-9822
Practice Address - Fax:330-538-9820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility