Healthcare Provider Details

I. General information

NPI: 1356452908
Provider Name (Legal Business Name): ST. JOHN VILLAS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 W BROADWAY ST
COLLINSVILLE OK
74021-1625
US

IV. Provider business mailing address

2300 WEST BROADWAY
COLLINSVILLE OK
74021-1625
US

V. Phone/Fax

Practice location:
  • Phone: 918-371-2545
  • Fax: 918-371-2738
Mailing address:
  • Phone: 918-371-2545
  • Fax: 918-371-2738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH7207-7207
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number375504
License Number StateOK

VIII. Authorized Official

Name: MR. DONALD W PEARCE
Title or Position: ADMINISTRATOR
Credential:
Phone: 918-371-2545