Basic Information
| Provider Information | |||||||||
| NPI: | 1265510655 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLOWOOD OF GREAT BARRINGTON INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | FAIRVIEW COMMONS NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 CHRISTIAN HILL RD | ||||||||
| Address2: | |||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012301108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135284560 | ||||||||
| FaxNumber: | 4135285691 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 CHRISTIAN HILL RD | ||||||||
| Address2: | |||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012301108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135284560 | ||||||||
| FaxNumber: | 4135285691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 03/23/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4134472996 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0821 | MA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00968507 | 05 | NY | MEDICAID | 00508723 | 05 | NY | MEDICAID | 0930156 | 05 | MA | MEDICAID | 0925675 | 05 | MA | MEDICAID | 1905295 | 05 | MA | MEDICAID |