=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558176917
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLOW GLEN CARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2025
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6253 BERRY LN
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95503-6605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-502-3623
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1547 PLUMAS CT
-----------------------------------------------------
City | YUBA CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95991-2960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-751-9900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JEFF T PAYNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-751-9904
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------