Healthcare Provider Details

I. General information

NPI: 1346363553
Provider Name (Legal Business Name): VILLA HOUSE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 WASHINGTON AVE
JOHNSTON CITY IL
62951-1536
US

IV. Provider business mailing address

1112 WASHINGTON AVE P O BOX 299
JOHNSTON CITY IL
62951-1536
US

V. Phone/Fax

Practice location:
  • Phone: 618-983-8513
  • Fax: 618-983-8513
Mailing address:
  • Phone: 618-983-8513
  • Fax: 618-983-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number94S200
License Number StateIL

VIII. Authorized Official

Name: ROBIN DODSON
Title or Position: EXEC. DIRECTOR
Credential:
Phone: 618-983-8513