Healthcare Provider Details

I. General information

NPI: 1841465689
Provider Name (Legal Business Name): WILLOW FAMILY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 TEACO RD SUITE A
KENNETT MO
63857-3266
US

IV. Provider business mailing address

304 TEACO RD SUITE A
KENNETT MO
63857-3266
US

V. Phone/Fax

Practice location:
  • Phone: 573-888-0303
  • Fax: 573-888-0304
Mailing address:
  • Phone: 573-888-0303
  • Fax: 573-888-0304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMY D LEDBETTER
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 573-651-4488