Basic Information
| Provider Information | |||||||||
| NPI: | 1033348883 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLOW TREE MANOR - UHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 780 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265070780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042937401 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Practice Location | |||||||||
| Address1: | 1263 S GEORGE ST | ||||||||
| Address2: | |||||||||
| City: | CHARLES TOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254144384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047256575 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2009 | ||||||||
| LastUpdateDate: | 07/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | MCDANIEL | ||||||||
| AuthorizedOfficialFirstName: | ROBYN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 3042935033 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0011526000 | 05 | WV | MEDICAID |