Willow Place Living Center, LLC

Primary specialty

Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X

License

NH3203-3203 Issued in OK

Legal business name

WILLOW PLACE LIVING CENTER, LLC

Doing business as

Willow Place

Practice address

622 S Alabama St
Wetumka, OK 74883

Phone

(405) 452-3278

Fax

(405) 452-5154

NPI assigned

Oct 19, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Donna R Simmons

Title

Office Manager

Phone

(405) 380-6671

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Willow Place Doing business as

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1366524423. Details of each certification follow.

• CCN 37G119 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 37G119

Legal name

Heartway at Pioneer Living Center - Maple Place

Certification status

Active

Provider type (POS)

Intermediate care facility for individuals with intellectual disabilities

Participating since

Aug 19, 2004

Last certification

Mar 27, 2025

Beds

16

Ownership / control type

Private (non-profit)

Facility address

622 South Alabama
Wetumka, OK 74883

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

Maple Place3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

• Maple Place Living Center, LLC

  dba Maple Place

  • Intellectual Disabilities Intermediate Care Facility
  • Wetumka, OK
  • NPI 1558446823
  NPD tax ID
• Oak Place Living Center, LLC

  dba Oak Place

  • Intellectual Disabilities Intermediate Care Facility
  • Wetumka, OK
  • NPI 1114002987
  NPD tax ID

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Brandon King, D.O.

  • Family Medicine Physician
  • Gore, OK
  • NPI 1609173038
  NPD (past)
• Angela Marie McGuire, D.O.

  • General Practice Physician
  • Oklahoma City, OK
  • NPI 1053492256
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1161216000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1673481600000",
    "number": "1366524423",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 488",
            "city": "WELEETKA",
            "state": "OK",
            "postal_code": "748800488",
            "telephone_number": "405-786-2266",
            "fax_number": "405-786-2388"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "622 S ALABAMA ST",
            "city": "WETUMKA",
            "state": "OK",
            "postal_code": "74883",
            "telephone_number": "405-452-3278",
            "fax_number": "405-452-5154"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WILLOW PLACE LIVING CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-19",
        "last_updated": "2023-01-12",
        "certification_date": "2023-01-12",
        "status": "A",
        "authorized_official_last_name": "SIMMONS",
        "authorized_official_first_name": "DONNA",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "405-380-6671",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "OK",
            "license": "NH3203-3203",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200106050A",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Willow Place",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Tyler Drug
• Christopher Jason Tyler, RPH
• Hetlevia R Vilar-Jensen, M.D.
• Wetumka Indian Health Clinic
• Wetumka Public Schools

• Intellectual Disabilities Intermediate Care Facility in Wetumka, OK
• Providers in Wetumka, OK by specialty
• Intellectual Disabilities Intermediate Care Facility in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 12, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.