1962528695 NPI number — WILLOW CREEK

Table of content: (NPI 1962528695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962528695 NPI number — WILLOW CREEK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLOW CREEK
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962528695
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 FELLOWSHIP RD
Provider Second Line Business Mailing Address:
SUITE 360
Provider Business Mailing Address City Name:
MOUNT LAUREL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08054-3415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-813-2000
Provider Business Mailing Address Fax Number:
856-813-2020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 FELLOWSHIP RD
Provider Second Line Business Practice Location Address:
SUITE 360
Provider Business Practice Location Address City Name:
MOUNT LAUREL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08054-3415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-813-2000
Provider Business Practice Location Address Fax Number:
856-813-2020
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
TRAMELL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
REGIONAL RESIDENT ACCOUNTING MGR
Authorized Official Telephone Number:
856-813-2000

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  061808 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4498607 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4499301 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com