Provider Demographics
NPI:1942544820
Name:WILLOW CREEK GROUP HOME
Entity Type:Organization
Organization Name:WILLOW CREEK GROUP HOME
Other - Org Name:WILLOW CREEK SOUTH GROUP HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-297-4256
Mailing Address - Street 1:1007 OLD 71 HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MO
Mailing Address - Zip Code:64720
Mailing Address - Country:US
Mailing Address - Phone:816-297-2037
Mailing Address - Fax:
Practice Address - Street 1:RURAL ROUTE 2, BOX 27
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MO
Practice Address - Zip Code:64720
Practice Address - Country:US
Practice Address - Phone:816-297-4256
Practice Address - Fax:816-297-8956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOWC2-0252-0712320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO320900000XMedicaid