Healthcare Provider Details

I. General information

NPI: 1942711304
Provider Name (Legal Business Name): BLUE RIDGE HEALTHCARE WILLOW TRACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 03/25/2019
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

1406 E PUSHMATAHA ST
BUTLER AL
36904-2728
US

V. Phone/Fax

Practice location:
  • Phone: 205-459-5506
  • Fax:
Mailing address:
  • Phone:
  • 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: ADMINISTRATOR ADMINISTRATOR
Title or Position: ADMINISTRATOR
Credential:
Phone: 205-459-5506