Provider Demographics
NPI:1538281019
Name:WILLOW CREEK ISL, LLC
Entity Type:Organization
Organization Name:WILLOW CREEK ISL, LLC
Other - Org Name:WILLOW CREEK GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DENISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-225-8214
Mailing Address - Street 1:1008 EDITH AVE.
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MO
Mailing Address - Zip Code:64720
Mailing Address - Country:US
Mailing Address - Phone:816-225-8214
Mailing Address - Fax:816-297-4032
Practice Address - Street 1:1008 EDITH AVE.
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MO
Practice Address - Zip Code:64720
Practice Address - Country:US
Practice Address - Phone:816-225-8214
Practice Address - Fax:816-297-4032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO855188900320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities