Provider Demographics
NPI:1336124643
Name:WILLOW BLUFF LLC
Entity Type:Organization
Organization Name:WILLOW BLUFF LLC
Other - Org Name:THE WILLOWS OF KILGORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SONDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCALCO
Authorized Official - Suffix:
Authorized Official - Credentials:LNFA
Authorized Official - Phone:903-983-7775
Mailing Address - Street 1:1901 WHIPPORWILL LN
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-3880
Mailing Address - Country:US
Mailing Address - Phone:903-983-7775
Mailing Address - Fax:
Practice Address - Street 1:1901 WHIPPORWILL LN
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3880
Practice Address - Country:US
Practice Address - Phone:903-983-7775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114059314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676007Medicare ID - Type Unspecified