Provider Demographics
NPI:1093808529
Name:SHEPHERD OF THE VALLEY LUTHERAN RETIREMENT SERVICES, INC.
Entity Type:Organization
Organization Name:SHEPHERD OF THE VALLEY LUTHERAN RETIREMENT SERVICES, INC.
Other - Org Name:SHEPHERD OF THE VALLEY - BOARDMAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE DIRECTOR/CFO
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:N
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-530-4038
Mailing Address - Street 1:5525 SILICA ROAD
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-1002
Mailing Address - Country:US
Mailing Address - Phone:330-530-4038
Mailing Address - Fax:330-530-4039
Practice Address - Street 1:7148 WEST BLVD.
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-4336
Practice Address - Country:US
Practice Address - Phone:330-726-9061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4706314000000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0346030Medicaid
365580Medicare Oscar/Certification
0293960001Medicare NSC