Organization
VILLA GROVE ASSISTED LIVING
Active
Other names
JOHNSON HOME ASSISTED LIVING, INC.
Organization subpart
No
Provider details
NPI number
Authorized official
PAUL SPICOLA (VICE-PRESIDENT)
(719) 369-4567
Entity
Organization
Contact information
Practice address
403 W 13TH ST, PUEBLO, CO 81003-2748
(719) 543-0305
(719) 562-9684
Mailing address
403 W 13TH ST, PUEBLO, CO 81003-2748
(719) 543-0305
(719) 562-9684
Taxonomy
Speciality
Code
Description
License number
State
3104A0625X
Assisted Living Facility (Mental Illness)
Primary
230602
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
26420554
—
CO
Enumeration date
12/30/2015
Last updated
12/30/2015
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