Organization
ST. JOHN'S VILLA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID L. LYON (PRESIDENT)
(330) 627-9789
Entity
Organization
Contact information
Practice address
701 CREST ST NW, CARROLLTON, OH 44615-8425
(330) 627-9789
(330) 627-4826
Mailing address
701 CREST ST NW, PO BOX 457, CARROLLTON, OH 44615-8425
(330) 627-9789
(330) 627-4826
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
1010128
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
M1000179
MRDD PROVIDER
OH
Enumeration date
12/01/2006
Last updated
06/16/2008
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