Provider Demographics
NPI:1083190920
Name:ST. JOHN'S HEALING COMMUNITY BOARD
Entity Type:Organization
Organization Name:ST. JOHN'S HEALING COMMUNITY BOARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-344-5008
Mailing Address - Street 1:222 GOETHE AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-3306
Mailing Address - Country:US
Mailing Address - Phone:618-344-5008
Mailing Address - Fax:
Practice Address - Street 1:1015B CENTURY DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3772
Practice Address - Country:US
Practice Address - Phone:618-656-7090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care