Provider Demographics
NPI:1962606632
Name:ST JOHNS HOME
Entity type:Organization
Organization Name:ST JOHNS HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:616-235-2090
Mailing Address - Street 1:PO BOX 120125
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49528-0103
Mailing Address - Country:US
Mailing Address - Phone:616-235-2090
Mailing Address - Fax:616-235-2099
Practice Address - Street 1:2355 KNAPP ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-4415
Practice Address - Country:US
Practice Address - Phone:616-235-2090
Practice Address - Fax:616-235-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder