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General NPI Number Information
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NPI Number | 1114386745
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Entity Type | Organization
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Legal Business Name | ST. JOHN'S RETIREMENT VILLAGE, INC.
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Dates
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Enumeration Date | 02/10/2016
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Last Update Date | 02/10/2016
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Provider Practice Location Address
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Address Line | 135 WOODLAND AVE
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City | WOODLAND
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State | CA
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Zip | 95695-2701
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Country | US
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Telephone | 530-662-1290
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Fax | 530-662-0852
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Provider Business Mailing Address
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Address Line | 135 WOODLAND AVE
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City | WOODLAND
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State | CA
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Zip | 95695-2701
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Country | US
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Telephone | 530-662-1290
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Fax | 530-662-0852
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Authorized Official
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Title or Position | CEO
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Name | MARY THERESE BROWN
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Credential | MSG
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Telephone | 530-662-1290
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 5703000654
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License Number State | CA
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