Provider Demographics
NPI:1093156317
Name:WILLOW GLEN CARE CENTER
Entity Type:Organization
Organization Name:WILLOW GLEN CARE CENTER
Other - Org Name:TRINITY PINES
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-751-9902
Mailing Address - Street 1:1547 PLUMAS CT
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-2960
Mailing Address - Country:US
Mailing Address - Phone:530-751-9900
Mailing Address - Fax:530-751-9915
Practice Address - Street 1:2753 WHITE AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-0496
Practice Address - Country:US
Practice Address - Phone:530-413-9252
Practice Address - Fax:530-413-9476
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLOW GLEN CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-15
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA045002488320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness