Healthcare Provider Details

I. General information

NPI: 1912822214
Provider Name (Legal Business Name): WILLOW GARDEN OF HANNIBAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 PLEASANT ST
HANNIBAL MO
63401-2600
US

IV. Provider business mailing address

1600 AVE OF THE STATES STE 309
LAKEWOOD NJ
08701-5181
US

V. Phone/Fax

Practice location:
  • Phone: 573-221-6000
  • Fax: 573-221-6172
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: AVROHOM RIBIAT
Title or Position: MANAGER
Credential:
Phone: 847-555-0101