Willow Ridge Hospice LLC
Organization Active NPI Community Based Hospice Care Agency · Havana, IL
NPI 1972228310 · NPPES record last updated Dec 22, 2023
Key facts
- NPI
- 1972228310
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community Based Hospice Care Agency 251G00000X
- Legal business name
- WILLOW RIDGE HOSPICE LLC
- Practice address
- 536 S Schrader Ave
Havana, IL 62644-1770 - Phone
- (309) 338-3635
- NPI assigned
- Oct 7, 2022
- Organization subpart
- No
Authorized official
- Name
- Hallie S Decapp
- Title
- Owner/Ceo
- Phone
- (309) 338-3635
Owners & managing parties with NPI records 1
Practitioners 1
-
Amy Svob, APN
Affiliated clinicians 2
-
Kenneth R. Krock, MD
Medicare Care Compare: Hospice
- Listed as
- Willow Ridge Hospice, LLC
- Certified
- Aug 28, 2023
- Medicare certification status
- Active
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 14D2273614 | Willow Ridge Hospice | Certificate of waiver | Dec 14, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in IL
Hospice certification: CCN 141726
- Legal name
- WILLOW RIDGE HOSPICE LLC
- Certification status
- Active
- Provider type (POS)
- Hospice
- Participating since
- Aug 28, 2023
- Last certification
- Aug 17, 2023
- Ownership / control type
- Proprietary - Corporation
- Organization structure
- LLC · Proprietary
- Incorporated
- Aug 15, 2022 in IL
- Enrollment address
- 536 South Schrader
Havana, IL 62644
All disclosed owners & managing parties 6
| Name | Role | Since | Share |
|---|---|---|---|
| Gralda, LLC |
5% Or Greater Direct Ownership Interest | Dec 28, 2023 | 40% |
| Diana Kelly |
Corporate Officer |
Aug 1, 2022 | |
| Hallie Decapp |
5% Or Greater Direct Ownership Interest |
Aug 15, 2022 | 60% |
| Corporate Officer |
Aug 15, 2022 | ||
| W-2 Managing Employee | Aug 15, 2022 | ||
| Tina Roddis |
W-2 Managing Employee |
Jun 8, 2026 | |
| Maria Rhodora Kabatay Lee Ho |
Contracted Managing Employee |
Nov 17, 2022 | |
| Gregory S Thome |
5% Or Greater Indirect Ownership Interest | Dec 28, 2023 | 40% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20230705002526 | IL | Part a Provider - Hospice | 7416316732 | Practice locations: Havana, IL |
| O20260430000071 | IL | Part B Supplier - Clinic/Group Practice | 7416316732 |
Receives reassigned benefits from 1 practitioner Practice locations: Havana, IL |
National Provider Directory
Locations
536 S Schrader Ave
Havana, IL 62644
Phone (309) 338-3635
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community Based Hospice Care Agency | 251G00000X | Yes |
Addresses
Primary practice location
536 S Schrader Ave
Havana, IL 62644-1770
Mailing address
536 S Schrader Ave
Havana, IL 62644-1770
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | hallie.decapp@willowridgehospice.com |
Other providers in Havana, IL
- Richard W Wagoner
- Makayla Renee Watson
- Kristi A White
- Morgan M Wiggs
- Willow Brook Counseling and Wellness, PLLC
- Megan Wilson
- Tad A Yetter
All providers in Havana, IL · Community Based Hospice Care Agency in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 22, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.