Provider Demographics
NPI:1902889306
Name:ST. EDWARD HOME
Entity Type:Organization
Organization Name:ST. EDWARD HOME
Other - Org Name:THE VILLAGE AT ST. EDWARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V.P. FINANCE/CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RENKAS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:330-666-1183
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:330-666-2721
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:330-666-2721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1181N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0127900Medicaid
OH0127900Medicaid