Provider Demographics
NPI:1124186093
Name:WILLOW CREST, INC.
Entity Type:Organization
Organization Name:WILLOW CREST, INC.
Other - Org Name:CRESTVIEW MANOR, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-473-6339
Mailing Address - Street 1:1410 E BUENA VENTURA ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-2825
Mailing Address - Country:US
Mailing Address - Phone:719-473-6339
Mailing Address - Fax:719-448-9301
Practice Address - Street 1:1209 E. CARAMILLO ST.
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909
Practice Address - Country:US
Practice Address - Phone:719-473-6339
Practice Address - Fax:719-448-9301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAL-1024310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04141552Medicaid