Healthcare Provider Details

I. General information

NPI: 1780227140
Provider Name (Legal Business Name): CREATIVE LIFE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1637 ATHENS HWY STE B
GRAYSON GA
30017-1768
US

IV. Provider business mailing address

1637 ATHENS HWY
GRAYSON GA
30017-1768
US

V. Phone/Fax

Practice location:
  • Phone: 678-344-8269
  • Fax: 888-627-6444
Mailing address:
  • Phone: 678-344-8268
  • Fax: 888-627-6444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name: MUHAMMAD S AHMED
Title or Position: CEO
Credential: MD
Phone: 678-344-8268