Provider Demographics
NPI:1003273053
Name:VILLA GROVE ASSISTED LIVING HOME
Entity Type:Organization
Organization Name:VILLA GROVE ASSISTED LIVING HOME
Other - Org Name:JOHNSON ASSISTED LIVING HOME, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SPICOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-369-4567
Mailing Address - Street 1:715 E B ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3504
Mailing Address - Country:US
Mailing Address - Phone:719-544-1561
Mailing Address - Fax:719-542-6539
Practice Address - Street 1:715 E B ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3504
Practice Address - Country:US
Practice Address - Phone:719-544-1561
Practice Address - Fax:719-542-6539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23W276310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility