=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710292883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLOWBEND RETREATS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2010
-----------------------------------------------------
Last Update Date | 08/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2033 WOOD ST SUITE 215
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34237-7900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-328-8953
-----------------------------------------------------
Fax | 941-866-0427
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2033 WOOD ST SUITE 215
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34237-7900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-328-8953
-----------------------------------------------------
Fax | 941-866-0427
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. MICHAEL DYLAN GREGORY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-328-8953
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 12-58-AD-6213-01
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------