MEDICARE: HALLOWSTONE WILLMAR OPERATING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1871463315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HALLOWSTONE WILLMAR OPERATING LLC

Provider Business Mailing Address
First Line	:	12811 KENWOOD LN STE 218
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-5645
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 19TH AVE SW
Second Line	:
City	:	WILLMAR
State	:	MN
Zip	:	56201-4940
Country	:	US
Telephone Number	:	239-292-1513
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	AYLA HARWOOD
Credential	:
Telephone Number	:	239-292-1513

Provider Enumeration Date	:	11/10/2025
Last Update Date	:	12/11/2025

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