Provider Demographics
NPI:1427299726
Name:WILLOW CREEK HOME CARE OF ST. GEORGE, L.L.C.
Entity type:Organization
Organization Name:WILLOW CREEK HOME CARE OF ST. GEORGE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:TRACE
Authorized Official - Middle Name:D
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:801-281-9669
Mailing Address - Street 1:1935 VINE ST
Mailing Address - Street 2:SUITE 420
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-2192
Mailing Address - Country:US
Mailing Address - Phone:801-281-9669
Mailing Address - Fax:
Practice Address - Street 1:229 E SAINT GEORGE BLVD
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2970
Practice Address - Country:US
Practice Address - Phone:888-394-5569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health