Provider Demographics
NPI:1003010158
Name:CHRISTUS ST. JOSEPH VILLA
Entity Type:Organization
Organization Name:CHRISTUS ST. JOSEPH VILLA
Other - Org Name:CHRISTUS MARIAN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:MS
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:JASMIN
Authorized Official - Last Name:HENNIG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-468-6856
Mailing Address - Street 1:451 BISHOP FEDERAL LN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2357
Mailing Address - Country:US
Mailing Address - Phone:801-487-7557
Mailing Address - Fax:801-487-1112
Practice Address - Street 1:451 BISHOP FEDERAL LN
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2357
Practice Address - Country:US
Practice Address - Phone:801-487-7557
Practice Address - Fax:801-487-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT282J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282J00000XHospitalsReligious Nonmedical Health Care Institution
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========009Medicaid
UT=========009Medicaid