Healthcare Provider Details

I. General information

NPI: 1518458249
Provider Name (Legal Business Name): CREATE IT KIDS CLUB, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 MARKET BLVD STE 530-251
ROSWELL GA
30076-6708
US

IV. Provider business mailing address

1425 MARKET BLVD STE 530-251
ROSWELL GA
30076-6708
US

V. Phone/Fax

Practice location:
  • Phone: 678-235-4333
  • Fax:
Mailing address:
  • Phone: 678-235-4333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2050X
TaxonomyRespite Care Camp
License Number
License Number State

VIII. Authorized Official

Name: TAMEKA ANDERSON
Title or Position: BEHAVIOR SPECIALIST
Credential:
Phone: 678-235-4333