Provider Demographics
NPI:1053791533
Name:SELF-DIRECTED LIVING, LLC
Entity type:Organization
Organization Name:SELF-DIRECTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:POZDERAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-273-5494
Mailing Address - Street 1:6721 GRAFTON RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY CITY
Mailing Address - State:OH
Mailing Address - Zip Code:44280-9705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6721 GRAFTON RD
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:OH
Practice Address - Zip Code:44280-9705
Practice Address - Country:US
Practice Address - Phone:330-273-5494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0119312Medicaid