1891820130 NPI number — CREATIVE COMMUNITY SERVICE, INC.

Table of content: (NPI 1891820130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891820130 NPI number — CREATIVE COMMUNITY SERVICE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREATIVE COMMUNITY SERVICE, 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:
1891820130
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4487 PARK DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
NORCROSS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30093-2964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-469-6226
Provider Business Mailing Address Fax Number:
678-894-4081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4487 PARK DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NORCROSS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30093-2964
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-469-6226
Provider Business Practice Location Address Fax Number:
678-894-4081
Provider Enumeration Date:
02/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PALLON
Authorized Official First Name:
CATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
770-469-6226

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  060-R-0018 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 060-R-0018 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251S00000X , with the licence number: CP-FC0040079 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000565375AA , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375AC , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375J , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375Y , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375AD , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375AF , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375AL , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375AN , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375N , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375P , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375U , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375AB , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375AK , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375M , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375V , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375W , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375Z , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000565375L , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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