1053853192 NPI number — CREATIVE CHILD CARE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053853192 NPI number — CREATIVE CHILD CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREATIVE CHILD CARE, 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:
1053853192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95202-3029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-941-9100
Provider Business Mailing Address Fax Number:
209-941-9110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4719 QUAIL LAKES DR
Provider Second Line Business Practice Location Address:
G-237
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95207-5267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-941-9100
Provider Business Practice Location Address Fax Number:
209-941-9110
Provider Enumeration Date:
11/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
EISON
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
209-941-9100

Provider Taxonomy Codes

  • Taxonomy code: 251300000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39155742 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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