Healthcare Provider Details

I. General information

NPI: 1215706627
Provider Name (Legal Business Name): WILLOWOOD OF EDISON, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2023
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19818 HARTFORD ST
EDISON GA
39846-5808
US

IV. Provider business mailing address

PO BOX 947
PERRY GA
31069-0947
US

V. Phone/Fax

Practice location:
  • Phone: 229-835-2186
  • Fax:
Mailing address:
  • Phone: 478-714-0246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JAMES N PETTIS
Title or Position: PRESIDENT
Credential:
Phone: 478-714-0246