Provider Demographics
NPI:1003861089
Name:WILLOW CREEK HEALTHCARE CENTER, LLC
Entity Type:Organization
Organization Name:WILLOW CREEK HEALTHCARE CENTER, LLC
Other - Org Name:WILLOW CREEK HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:650 W ALLUVIAL AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6716
Mailing Address - Country:US
Mailing Address - Phone:559-323-6200
Mailing Address - Fax:559-323-4665
Practice Address - Street 1:650 W ALLUVIAL AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6716
Practice Address - Country:US
Practice Address - Phone:559-323-6200
Practice Address - Fax:559-323-4665
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-24
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA040000418314000000X
CA040000118314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55652GMedicaid
CA555652Medicare Oscar/Certification