MEDICARE: VILLA HOUSE, INC

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	302F00000X	Exclusive Provider Organization	94S200	IL

General Provider Information

NPI Number	:	1346363553
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLA HOUSE, INC

Provider Business Mailing Address
First Line	:	1112 WASHINGTON AVE
Second Line	:	P O BOX 299
City	:	JOHNSTON CITY
State	:	IL
Zip	:	62951-1536
Country	:	US
Telephone Number	:	618-983-8513
Fax Number	:	618-983-8513

Provider Business Practice Location Address
First Line	:	1112 WASHINGTON AVE
Second Line	:
City	:	JOHNSTON CITY
State	:	IL
Zip	:	62951-1536
Country	:	US
Telephone Number	:	618-983-8513
Fax Number	:	618-983-8513

Authorized Official
Title or Position	:	EXEC. DIRECTOR
Name	:	ROBIN DODSON
Credential	:
Telephone Number	:	618-983-8513

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	08/22/2020

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Directions to “VILLA HOUSE, INC ” Practice Location

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