Healthcare Provider Details

I. General information

NPI: 1003861089
Provider Name (Legal Business Name): WILLOW CREEK HEALTHCARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 02/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W ALLUVIAL AVE
CLOVIS CA
93611-6716
US

IV. Provider business mailing address

650 W ALLUVIAL AVE
CLOVIS CA
93611-6716
US

V. Phone/Fax

Practice location:
  • Phone: 559-323-6200
  • Fax: 559-323-4665
Mailing address:
  • Phone: 559-323-6200
  • Fax: 559-323-4665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number040000418
License Number StateCA

VIII. Authorized Official

Name: MICHAEL T. BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4752