Healthcare Provider Details

I. General information

NPI: 1083190920
Provider Name (Legal Business Name): ST. JOHN'S HEALING COMMUNITY BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2018
Last Update Date: 07/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015B CENTURY DR
EDWARDSVILLE IL
62025-3772
US

IV. Provider business mailing address

222 GOETHE AVE
COLLINSVILLE IL
62234-3306
US

V. Phone/Fax

Practice location:
  • Phone: 618-656-7090
  • Fax:
Mailing address:
  • Phone: 618-344-5008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. NANCY JO BERRY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 618-344-5008