Provider Demographics
NPI:1497084693
Name:WILLOW CREEK HEALTH CARE LLC
Entity Type:Organization
Organization Name:WILLOW CREEK HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TANDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HASTINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-282-6285
Mailing Address - Street 1:PO BOX 1095
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-1095
Mailing Address - Country:US
Mailing Address - Phone:405-282-6285
Mailing Address - Fax:405-282-5731
Practice Address - Street 1:2300 W NOBLE AVE
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-5504
Practice Address - Country:US
Practice Address - Phone:405-282-1686
Practice Address - Fax:405-282-5731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-17
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH4201314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100778230AMedicaid
OK100778230AMedicaid