Provider Demographics
NPI:1215209614
Name:WILLOW TREE MEDICAL CONCEPTS
Entity Type:Organization
Organization Name:WILLOW TREE MEDICAL CONCEPTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRANSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-264-2727
Mailing Address - Street 1:128 MEADOWVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5211
Mailing Address - Country:US
Mailing Address - Phone:828-264-2727
Mailing Address - Fax:828-264-2722
Practice Address - Street 1:128 MEADOWVIEW DR
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5211
Practice Address - Country:US
Practice Address - Phone:828-264-2727
Practice Address - Fax:828-264-2722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-31
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98-01223261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916167Medicaid