Provider Demographics
NPI:1174691927
Name:ST. JOHN'S VILLA
Entity type:Organization
Organization Name:ST. JOHN'S VILLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:LYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-627-9789
Mailing Address - Street 1:701 CREST ST NW
Mailing Address - Street 2:PO BOX 457
Mailing Address - City:CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:44615-8425
Mailing Address - Country:US
Mailing Address - Phone:330-627-9789
Mailing Address - Fax:330-627-4826
Practice Address - Street 1:701 CREST ST NW
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:44615-8425
Practice Address - Country:US
Practice Address - Phone:330-627-9789
Practice Address - Fax:330-627-4826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1010128320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHM1000179OtherMRDD PROVIDER