Provider Demographics
NPI:1275689903
Name:WILLOW RIDGE HEALTHCARE FACILITIES, LLC
Entity Type:Organization
Organization Name:WILLOW RIDGE HEALTHCARE FACILITIES, LLC
Other - Org Name:WILLOW RIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-225-2516
Mailing Address - Street 1:400 DERONDA ST
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001-1404
Mailing Address - Country:US
Mailing Address - Phone:715-268-8171
Mailing Address - Fax:
Practice Address - Street 1:400 DERONDA ST
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1404
Practice Address - Country:US
Practice Address - Phone:715-268-8171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2642314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20186400Medicaid
WI20186400Medicaid