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General NPI Number Information
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NPI Number | 1184490872
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Entity Type | Organization
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Legal Business Name | BLACK WILLOW HOLISTIC CENTER LLC
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Dates
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Enumeration Date | 12/04/2023
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Last Update Date | 12/12/2023
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Provider Practice Location Address
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Address Line | 301 OGLESBY ST
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City | SALEM
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State | IL
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Zip | 62881-2724
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Country | US
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Telephone | 618-292-8518
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Fax |
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Provider Business Mailing Address
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Address Line | 301 OGLESBY ST
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City | SALEM
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State | IL
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Zip | 62881-2724
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Country | US
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Telephone | 618-292-8518
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CANDICE ULLERY
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Credential | SBD
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Telephone | 618-292-8518
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 374K00000X
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Taxonomy Name | Religious Nonmedical Practitioner
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License Number |
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License Number State |
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