MEDICARE: ETS WILLOWBROOK AT MARION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	9909	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114420502
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETS WILLOWBROOK AT MARION

Provider Business Mailing Address
First Line	:	7225 DRUCILLA ST
Second Line	:
City	:	PICKERINGTON
State	:	OH
Zip	:	43147-7962
Country	:	US
Telephone Number	:	740-964-1240
Fax Number	:

Provider Business Practice Location Address
First Line	:	1580 S MARION AVE
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6913
Country	:	US
Telephone Number	:	386-752-4454
Fax Number	:

Authorized Official
Title or Position	:	SECRETARY/TREASURER
Name	:	MR. JON SKYLAR BURGESS
Credential	:
Telephone Number	:	614-565-5636

Provider Enumeration Date	:	03/13/2018
Last Update Date	:	03/13/2018

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