Provider Demographics
NPI:1659789915
Name:SELF
Entity Type:Organization
Organization Name:SELF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PESTA
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:440-933-4156
Mailing Address - Street 1:33803 ELECTRIC BLVD
Mailing Address - Street 2:E4
Mailing Address - City:AVONLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012
Mailing Address - Country:US
Mailing Address - Phone:440-933-4156
Mailing Address - Fax:
Practice Address - Street 1:33803 ELECTRIC BLVD
Practice Address - Street 2:E4
Practice Address - City:AVONLAKE
Practice Address - State:OH
Practice Address - Zip Code:44012
Practice Address - Country:US
Practice Address - Phone:440-933-4156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN080509251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health