Provider Demographics
NPI:1033086434
Name:MENDED WILLOW
Entity type:Organization
Organization Name:MENDED WILLOW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FLOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:LMBT,MMP
Authorized Official - Phone:910-286-2603
Mailing Address - Street 1:108 HAY ST STE 221
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-5686
Mailing Address - Country:US
Mailing Address - Phone:910-286-2603
Mailing Address - Fax:910-565-6014
Practice Address - Street 1:108 HAY ST STE 221
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5686
Practice Address - Country:US
Practice Address - Phone:910-286-2603
Practice Address - Fax:910-595-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-20
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty