Provider Demographics
NPI:1366438145
Name:ELIZA BRYANT VILLAGE
Entity type:Organization
Organization Name:ELIZA BRYANT VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:JD, LNHA
Authorized Official - Phone:216-361-6141
Mailing Address - Street 1:7201 WADE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103
Mailing Address - Country:US
Mailing Address - Phone:216-361-6141
Mailing Address - Fax:216-588-1982
Practice Address - Street 1:7201 WADE PARK AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103
Practice Address - Country:US
Practice Address - Phone:216-361-6141
Practice Address - Fax:216-588-1982
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELIZA BRYANT VILLAGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-27
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3660314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0612822Medicaid
OH366101Medicare UPIN
OH0612822Medicaid
OH1146490001Medicare NSC