Provider Demographics
NPI:1114386745
Name:ST. JOHN'S RETIREMENT VILLAGE, INC.
Entity Type:Organization
Organization Name:ST. JOHN'S RETIREMENT VILLAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:THERESE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MSG
Authorized Official - Phone:530-662-1290
Mailing Address - Street 1:135 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-2701
Mailing Address - Country:US
Mailing Address - Phone:530-662-1290
Mailing Address - Fax:530-662-0852
Practice Address - Street 1:135 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2701
Practice Address - Country:US
Practice Address - Phone:530-662-1290
Practice Address - Fax:530-662-0852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5703000654310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
056138OtherPTN
CA1891914784Medicaid
CA1891914784Medicaid