Provider Demographics
NPI:1649027459
Name:ST. EDWARD HOME
Entity type:Organization
Organization Name:ST. EDWARD HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:234-466-5214
Mailing Address - Street 1:3131 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-2613
Mailing Address - Country:US
Mailing Address - Phone:330-666-1183
Mailing Address - Fax:
Practice Address - Street 1:3131 SMITH RD
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-2613
Practice Address - Country:US
Practice Address - Phone:330-666-1183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2832395Medicaid