Basic Information
| Provider Information | |||||||||
| NPI: | 1669453403 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRECKSVILLE LEASING CO., LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PINE VALLEY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 ASHWOOD DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452412465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134897100 | ||||||||
| FaxNumber: | 5135301359 | ||||||||
| Practice Location | |||||||||
| Address1: | 4360 BRECKSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | RICHFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442869457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306596166 | ||||||||
| FaxNumber: | 3306593676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 10/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | HUBBARD | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | DIR OF A/R | ||||||||
| AuthorizedOfficialTelephone: | 5135301327 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1210 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2607147 | 05 | OH | MEDICAID |