1629272919 NPI number — CREATIVE NETWORKS, LLC

Table of content: (NPI 1629272919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629272919 NPI number — CREATIVE NETWORKS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREATIVE NETWORKS, 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:
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:
1629272919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 N WHITTINGTON PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40222-7101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-866-0860
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 W BEHREND DR
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85027-4403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-780-0053
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WHOBREY
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER ENROLLMENT
Authorized Official Telephone Number:
502-630-7249

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 908577 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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