MEDICARE: WILLOW GLEN CARE CENTER

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	320800000X	Mental Illness Community Based Residential Treatment Facility	045002807	CA

General Provider Information

NPI Number	:	1932552072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW GLEN CARE CENTER

Provider Business Mailing Address
First Line	:	1547 PLUMAS CT
Second Line	:
City	:	YUBA CITY
State	:	CA
Zip	:	95991-2960
Country	:	US
Telephone Number	:	530-751-9900
Fax Number	:

Provider Business Practice Location Address
First Line	:	556 COHASSET RD
Second Line	:
City	:	CHICO
State	:	CA
Zip	:	95926-2212
Country	:	US
Telephone Number	:	530-755-7167
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	JEFF PAYNE
Credential	:
Telephone Number	:	530-751-9904

Provider Enumeration Date	:	07/13/2016
Last Update Date	:	07/27/2021

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