=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598092298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE WILLOWS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2009
-----------------------------------------------------
Last Update Date | 11/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3440 NILES RD
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-9601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-428-0715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3196 KRAFT AVE SE SUITE 200
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49512-2078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-464-1564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | AUDREY HENRIQUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 269-428-0715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL110283729
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL110283726
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------