Provider Demographics
NPI:1669453403
Name:BRECKSVILLE LEASING CO., LLC
Entity Type:Organization
Organization Name:BRECKSVILLE LEASING CO., LLC
Other - Org Name:PINE VALLEY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF A/R
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-530-1327
Mailing Address - Street 1:4700 ASHWOOD DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-2465
Mailing Address - Country:US
Mailing Address - Phone:513-489-7100
Mailing Address - Fax:513-530-1359
Practice Address - Street 1:4360 BRECKSVILLE RD
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:OH
Practice Address - Zip Code:44286-9457
Practice Address - Country:US
Practice Address - Phone:330-659-6166
Practice Address - Fax:330-659-3676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1210314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2607147Medicaid
OH2607147Medicaid
OH5626620001Medicare NSC