Healthcare Provider Details

I. General information

NPI: 1316717523
Provider Name (Legal Business Name): WILLOW TREE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2046 JONATHAN CREEK RD
ARTHUR IL
61911-6108
US

IV. Provider business mailing address

2046 JONATHAN CREEK RD
ARTHUR IL
61911-6108
US

V. Phone/Fax

Practice location:
  • Phone: 217-962-0614
  • Fax:
Mailing address:
  • Phone: 217-962-0614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMY BROOKE UPCHURCH
Title or Position: OWNER
Credential:
Phone: 217-962-0614