Provider Demographics
NPI:1346346335
Name:WILLOW WELLNESS CENTER, P.A.
Entity Type:Organization
Organization Name:WILLOW WELLNESS CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:NELL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-596-0602
Mailing Address - Street 1:820 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8326
Mailing Address - Country:US
Mailing Address - Phone:903-596-0602
Mailing Address - Fax:903-596-0620
Practice Address - Street 1:820 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8326
Practice Address - Country:US
Practice Address - Phone:903-596-0602
Practice Address - Fax:903-596-0620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX031016101Medicaid
TX031016101Medicaid