Provider Demographics
NPI:1720355076
Name:SELFRIDGE LEASING, LLC
Entity Type:Organization
Organization Name:SELFRIDGE LEASING, LLC
Other - Org Name:VALLEY OAKS CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ELI
Authorized Official - Middle Name:M
Authorized Official - Last Name:GUNZBURG
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, LNHA
Authorized Official - Phone:440-658-1040
Mailing Address - Street 1:29225 CHAGRIN BLVD.
Mailing Address - Street 2:SUITE 230
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:440-658-1040
Mailing Address - Fax:866-629-9730
Practice Address - Street 1:500 SELFRIDGE STREET
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43924
Practice Address - Country:US
Practice Address - Phone:330-385-5001
Practice Address - Fax:866-629-9730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
313M00000X, 314000000X
OH313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0058723Medicaid
OH366306OtherMEDICARE CCN