Provider Demographics
NPI:1265500656
Name:WILLOW OAK, INC.
Entity Type:Organization
Organization Name:WILLOW OAK, INC.
Other - Org Name:CENTENNIAL PARK CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:TIMPSON
Authorized Official - Last Name:YARRISH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, CNM
Authorized Official - Phone:928-875-8750
Mailing Address - Street 1:PO BOX 1549
Mailing Address - Street 2:
Mailing Address - City:COLORADO CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86021-1549
Mailing Address - Country:US
Mailing Address - Phone:928-875-8750
Mailing Address - Fax:928-875-8752
Practice Address - Street 1:1675 S. BERRY KNOLL BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO CITY
Practice Address - State:AZ
Practice Address - Zip Code:86021-1549
Practice Address - Country:US
Practice Address - Phone:928-875-8750
Practice Address - Fax:928-875-8752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN083151363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty