Provider Demographics
NPI:1598325201
Name:ELIZA BRYANT VILLAGE
Entity Type:Organization
Organization Name:ELIZA BRYANT VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:JD, MNO, LNHA
Authorized Official - Phone:216-658-1821
Mailing Address - Street 1:7201 WADE PARK AVE.
Mailing Address - Street 2:
Mailing Address - City:CLEAVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103
Mailing Address - Country:US
Mailing Address - Phone:216-361-6141
Mailing Address - Fax:216-588-1982
Practice Address - Street 1:7201 WADE PARK AVE.
Practice Address - Street 2:
Practice Address - City:CLEAVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103
Practice Address - Country:US
Practice Address - Phone:216-361-6141
Practice Address - Fax:216-588-1982
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELIZA BRYANT VILLAGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0612822Medicaid