1184915472 NPI number — CREATIVE RENEWAL & RESOLUTIONS, LLC

Table of content: (NPI 1184915472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184915472 NPI number — CREATIVE RENEWAL & RESOLUTIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREATIVE RENEWAL & RESOLUTIONS, LLC
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:
CREATIVE RENEWAL & RESOLUTIONS
Provider Other Organization Name Type Code:
3
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:
1184915472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1531 E BRADFORD PKWY
Provider Second Line Business Mailing Address:
STE 210-4
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65804-6566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-890-4083
Provider Business Mailing Address Fax Number:
417-890-4091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1531 E BRADFORD PKWY
Provider Second Line Business Practice Location Address:
STE 210-4
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-6566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-890-4083
Provider Business Practice Location Address Fax Number:
417-890-4091
Provider Enumeration Date:
04/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER, MANAGING MEMBER
Authorized Official Telephone Number:
417-890-4083

Provider Taxonomy Codes

  • Taxonomy code: 103TA0400X , with the licence number:  2009026793 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TB0200X , with the licence number: 2009026793 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 2009026793 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC1900X , with the licence number: 2009026793 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC2200X , with the licence number: 2009026793 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TH0100X , with the licence number: 2009026793 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TP2701X , with the licence number: 2009026793 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 2001004284 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 2001004284 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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