Provider Demographics
NPI:1710132345
Name:WILLOW CREEK ASSISTED LIVING
Entity Type:Organization
Organization Name:WILLOW CREEK ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-495-2999
Mailing Address - Street 1:23281 W. WILLOW FISHOOK RD
Mailing Address - Street 2:PO BOX 558
Mailing Address - City:WILLOW
Mailing Address - State:AK
Mailing Address - Zip Code:99688-0558
Mailing Address - Country:US
Mailing Address - Phone:907-495-2999
Mailing Address - Fax:907-495-9199
Practice Address - Street 1:23281 W. WILLOW FISHHOK RD
Practice Address - Street 2:
Practice Address - City:WILLOW
Practice Address - State:AK
Practice Address - Zip Code:99688-0558
Practice Address - Country:US
Practice Address - Phone:907-495-2999
Practice Address - Fax:907-495-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100142261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities