Basic Information
| Provider Information | |||||||||
| NPI: | 1356348221 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLOWCREEK REHAB AND NURSING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 WESTGATE ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603011007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129942306 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 N 64TH ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622233808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183978400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2005 | ||||||||
| LastUpdateDate: | 01/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3129942306 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 0041939 | IL | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 0041939 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0041939 | 01 | IL | FACILITY LICENSE NUMBER | OTHER |