=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932138823
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLOUGH HEALTHCARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2006
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9001 TAMIAMI TRL E
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34113-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-775-4500
-----------------------------------------------------
Fax | 239-755-2990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7074 GROVE RD # 129
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34609-8658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-978-1933
-----------------------------------------------------
Fax | 352-610-9996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR REVENUE CYCLE MANAGEMENT
-----------------------------------------------------
Name | TRACY ROBERTS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-895-0084
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number | 4212
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------