Provider Demographics
NPI:1346328994
Name:VILLAGE AT MARYMOUNT
Entity Type:Organization
Organization Name:VILLAGE AT MARYMOUNT
Other - Org Name:VILLA ST. JOSEPH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.O.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:216-587-8627
Mailing Address - Street 1:5200 MARYMOUNT VILLAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HTS.
Mailing Address - State:OH
Mailing Address - Zip Code:44125
Mailing Address - Country:US
Mailing Address - Phone:216-587-8627
Mailing Address - Fax:216-332-1619
Practice Address - Street 1:5200 MARYMOUNT VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2914
Practice Address - Country:US
Practice Address - Phone:216-587-8627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2463N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2710749Medicaid
OH2710749Medicaid