Provider Demographics
NPI:1003009747
Name:ST. JOHN'S/ST. VINCENT'S HOME FOR CHILDREN, INC
Entity Type:Organization
Organization Name:ST. JOHN'S/ST. VINCENT'S HOME FOR CHILDREN, INC
Other - Org Name:ST. JOHN'S HOME FOR CHILDREN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, ACSW
Authorized Official - Phone:304-242-5633
Mailing Address - Street 1:141 KEY AVE
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-7410
Mailing Address - Country:US
Mailing Address - Phone:304-242-5633
Mailing Address - Fax:304-243-4911
Practice Address - Street 1:141 KEY AVE
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-7410
Practice Address - Country:US
Practice Address - Phone:304-242-5633
Practice Address - Fax:304-243-4911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV238251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0023582001Medicaid