# WILLOW TERRACE

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1235138587
- **Authorized official:** MR. SAMUEL RUSSO (CORP. DIRECTOR OF FINANCE)
- **Authorized official phone:** (215) 456-6611

## Contact information

- **Practice address:** 1 PENN BLVD, PHILA, PA 19144-1476
- **Practice address phone:** (215) 456-6611
- **Practice address fax:** (215) 457-4304
- **Mailing address:** 1 PENN BLVD, PHILA, PA 19144-1476
- **Mailing address phone:** (215) 456-6611
- **Mailing address fax:** (215) 457-4304

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 072102 | PA | Yes |

## Other

- **Enumeration date:** 07/19/2005
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1007544140014 | — | PA |