Provider Demographics
NPI:1316015605
Name:WILLOWBROOK LLC
Entity Type:Organization
Organization Name:WILLOWBROOK LLC
Other - Org Name:WILLOWBROOK ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR, OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:HAIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-736-3727
Mailing Address - Street 1:1871 JULIE LN
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3525
Mailing Address - Country:US
Mailing Address - Phone:208-736-3727
Mailing Address - Fax:208-732-6047
Practice Address - Street 1:1871 JULIE LN
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3525
Practice Address - Country:US
Practice Address - Phone:208-736-3727
Practice Address - Fax:208-732-6047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-03
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRC-845310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8074013Medicaid