MEDICARE: SELF-DIRECTED LIVING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053791533
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELF-DIRECTED LIVING, LLC

Provider Business Mailing Address
First Line	:	6721 GRAFTON RD
Second Line	:
City	:	VALLEY CITY
State	:	OH
Zip	:	44280-9705
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6721 GRAFTON RD
Second Line	:
City	:	VALLEY CITY
State	:	OH
Zip	:	44280-9705
Country	:	US
Telephone Number	:	330-273-5494
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR/OWNER
Name	:	NATHAN POZDERAC
Credential	:
Telephone Number	:	330-273-5494

Provider Enumeration Date	:	06/01/2015
Last Update Date	:	06/01/2015

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