Provider Demographics
NPI:1235129586
Name:ABBEYVILLE HOUSE
Entity Type:Organization
Organization Name:ABBEYVILLE HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:TRIVANOVICH
Authorized Official - Last Name:POZDERAC
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:330-273-5494
Mailing Address - Street 1:791 PEARL RD
Mailing Address - Street 2:P.O. BOX 810
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-2528
Mailing Address - Country:US
Mailing Address - Phone:330-273-5494
Mailing Address - Fax:330-273-6199
Practice Address - Street 1:2525 ABBEYVILLE RD
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:OH
Practice Address - Zip Code:44280-9734
Practice Address - Country:US
Practice Address - Phone:330-273-5494
Practice Address - Fax:330-273-6199
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRANSITIONAL LIVING CENTERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-27
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5210186315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0919797Medicaid
OH36-G468Medicaid