MEDICARE: AL WILLOW TREE, LLC

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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1205096500
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AL WILLOW TREE, LLC

Provider Business Mailing Address
First Line	:	40 PALAFOX PL
Second Line	:	STE 400
City	:	PENSACOLA
State	:	FL
Zip	:	32502-5699
Country	:	US
Telephone Number	:	850-430-0000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1406 E PUSHMATAHA ST
Second Line	:
City	:	BUTLER
State	:	AL
Zip	:	36904-2728
Country	:	US
Telephone Number	:	205-459-5506
Fax Number	:	205-459-5503

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAMES RICHARDSON
Credential	:
Telephone Number	:	850-430-0000

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	10/05/2015

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