Provider Demographics
NPI:1629419239
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 POLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE DIRECTOR/C.F.O.
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:330-530-4038
Mailing Address - Street 1:5525 SILICA RD
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 1:301 W WESTERN RESERVE RD
Practice Address - Street 2:
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-3527
Practice Address - Country:US
Practice Address - Phone:330-726-7110
Practice Address - Fax:330-726-2517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5184310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0054967Medicaid