=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316717523
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLOW TREE WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2024
-----------------------------------------------------
Last Update Date | 01/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2046 JONATHAN CREEK RD
-----------------------------------------------------
City | ARTHUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61911-6108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-962-0614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2046 JONATHAN CREEK RD
-----------------------------------------------------
City | ARTHUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61911-6108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-962-0614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMY BROOKE UPCHURCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-962-0614
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------