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General NPI Number Information
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NPI Number | 1245580265
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Entity Type | Organization
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Legal Business Name | WILLOW TREE SUPPORT SERVICES LLC
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Dates
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Enumeration Date | 09/17/2012
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Last Update Date | 09/17/2012
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Provider Practice Location Address
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Address Line | 2905 W 9TH AVE
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City | OSHKOSH
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State | WI
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Zip | 54904-6504
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Country | US
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Telephone | 920-379-4388
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Fax |
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Provider Business Mailing Address
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Address Line | 2905 W 9TH AVE
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City | OSHKOSH
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State | WI
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Zip | 54904-6504
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JACOB TETZLAFF
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Credential |
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Telephone | 920-379-4388
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State | WI
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