Healthcare Provider Details

I. General information

NPI: 1205096500
Provider Name (Legal Business Name): AL WILLOW TREE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 E PUSHMATAHA ST
BUTLER AL
36904-2728
US

IV. Provider business mailing address

40 PALAFOX PL STE 400
PENSACOLA FL
32502-5699
US

V. Phone/Fax

Practice location:
  • Phone: 205-459-5506
  • Fax: 205-459-5503
Mailing address:
  • Phone: 850-430-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JAMES RICHARDSON
Title or Position: PRESIDENT
Credential:
Phone: 850-430-0000