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General NPI Number Information
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NPI Number | 1174691927
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Entity Type | Organization
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Legal Business Name | ST. JOHN'S VILLA
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Dates
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Enumeration Date | 12/01/2006
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Last Update Date | 06/16/2008
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Provider Practice Location Address
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Address Line | 701 CREST ST NW
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City | CARROLLTON
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State | OH
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Zip | 44615-8425
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Country | US
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Telephone | 330-627-9789
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Fax | 330-627-4826
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Provider Business Mailing Address
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Address Line | 701 CREST ST NW PO BOX 457
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City | CARROLLTON
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State | OH
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Zip | 44615-8425
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Country | US
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Telephone | 330-627-9789
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Fax | 330-627-4826
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Authorized Official
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Title or Position | PRESIDENT
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Name | DAVID L. LYON
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Credential |
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Telephone | 330-627-9789
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 1010128
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License Number State | OH
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