Provider Demographics
NPI:1831243070
Name:WILLOWOOD DEVELOPMENTAL CENTER
Entity type:Organization
Organization Name:WILLOWOOD DEVELOPMENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:ALFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-366-0123
Mailing Address - Street 1:1635 BOLING ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-4418
Mailing Address - Country:US
Mailing Address - Phone:601-366-0123
Mailing Address - Fax:
Practice Address - Street 1:1635 BOLING ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-4418
Practice Address - Country:US
Practice Address - Phone:601-366-0123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015618Medicaid
MS00770062Medicaid