1154517480 NPI number — CREATIVE LIVING CENTER

Table of content: (NPI 1154517480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154517480 NPI number — CREATIVE LIVING CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREATIVE LIVING CENTER
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:
1154517480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 948
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27835-0948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-757-0147
Provider Business Mailing Address Fax Number:
252-757-0147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4748 STANTONSBURG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27834-4794
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-757-0147
Provider Business Practice Location Address Fax Number:
252-757-0147
Provider Enumeration Date:
09/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARDY
Authorized Official First Name:
CHRISTINA
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
252-757-0147

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 261QA0600X . This is a "ADULT DAY CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 3409016 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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