Provider Demographics
NPI:1447240882
Name:ST PETER VILLA INC
Entity type:Organization
Organization Name:ST PETER VILLA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAE
Authorized Official - Middle Name:
Authorized Official - Last Name:WERHOVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-276-2021
Mailing Address - Street 1:141 N MCLEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2693
Mailing Address - Country:US
Mailing Address - Phone:901-276-2021
Mailing Address - Fax:901-725-3564
Practice Address - Street 1:141 N MCLEAN BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2693
Practice Address - Country:US
Practice Address - Phone:901-276-2021
Practice Address - Fax:901-725-3564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN255313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440447Medicaid
TN7440447Medicaid