1194343046 NPI number — CREEKSIDE PLACE, INC.

Table of content: (NPI 1194343046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194343046 NPI number — CREEKSIDE PLACE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREEKSIDE PLACE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194343046
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2995 WEIDEMANN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKSTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48348-1249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-346-4515
Provider Business Mailing Address Fax Number:
248-250-5999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7251 N BRIARCLIFF KNOLL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST BLOOMFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48322-4049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-327-5484
Provider Business Practice Location Address Fax Number:
248-250-5999
Provider Enumeration Date:
07/08/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BORSO
Authorized Official First Name:
PUJA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
248-346-4515

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AS630397523 . This is a "LICENSE NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".