Provider Demographics
NPI:1528429636
Name:WILLOW MEDICAL CENTER
Entity type:Organization
Organization Name:WILLOW MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/ PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-658-3830
Mailing Address - Street 1:20315 VENTURA BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-2449
Mailing Address - Country:US
Mailing Address - Phone:818-658-3830
Mailing Address - Fax:888-837-4246
Practice Address - Street 1:20315 VENTURA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2449
Practice Address - Country:US
Practice Address - Phone:818-658-3830
Practice Address - Fax:888-837-4246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103852261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1093934036OtherNPI