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General NPI Number Information
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NPI Number | 1114420502
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Entity Type | Organization
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Legal Business Name | ETS WILLOWBROOK AT MARION
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Dates
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Enumeration Date | 03/13/2018
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Last Update Date | 03/13/2018
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Provider Practice Location Address
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Address Line | 1580 S MARION AVE
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City | LAKE CITY
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State | FL
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Zip | 32025-6913
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Country | US
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Telephone | 386-752-4454
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Fax |
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Provider Business Mailing Address
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Address Line | 7225 DRUCILLA ST
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City | PICKERINGTON
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State | OH
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Zip | 43147-7962
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Country | US
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Telephone | 740-964-1240
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Fax |
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Authorized Official
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Title or Position | SECRETARY/TREASURER
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Name | MR. JON SKYLAR BURGESS
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Credential |
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Telephone | 614-565-5636
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 9909
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License Number State | FL
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