Provider Demographics
NPI:1134731789
Name:WILLOW HEALTH AND PERFORMANCE
Entity type:Organization
Organization Name:WILLOW HEALTH AND PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:REAU
Authorized Official - Last Name:BROADWATER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LD, CSCS
Authorized Official - Phone:937-642-9037
Mailing Address - Street 1:135 KENNY LN
Mailing Address - Street 2:
Mailing Address - City:CARDINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43315-9611
Mailing Address - Country:US
Mailing Address - Phone:937-642-9037
Mailing Address - Fax:
Practice Address - Street 1:4353 TULLER RD STE K
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-5071
Practice Address - Country:US
Practice Address - Phone:937-642-9037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty