Provider Demographics
NPI:1760819767
Name:WILLOW GLEN CARE CENTER
Entity Type:Organization
Organization Name:WILLOW GLEN CARE CENTER
Other - Org Name:REDWOOD CREEK
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-751-9904
Mailing Address - Street 1:1547 PLUMAS CT
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-2960
Mailing Address - Country:US
Mailing Address - Phone:530-751-9900
Mailing Address - Fax:530-751-9915
Practice Address - Street 1:414 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-3908
Practice Address - Country:US
Practice Address - Phone:707-459-6134
Practice Address - Fax:707-459-9252
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLOW GLEN CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-04
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA236803329320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherFEDERAL TAX IDENTIFICATION NUMBER