Healthcare Provider Details

I. General information

NPI: 1407125388
Provider Name (Legal Business Name): CREEKSIDE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 MOUNTAIN CREEK RD NE
SANDY SPRINGS GA
30328-5035
US

IV. Provider business mailing address

5800 MOUNTAIN CREEK RD NE
SANDY SPRINGS GA
30328-5035
US

V. Phone/Fax

Practice location:
  • Phone: 404-228-6554
  • Fax: 404-963-0555
Mailing address:
  • Phone: 404-228-6554
  • Fax: 404-963-0555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number39
License Number StateGA
# 8
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW004998
License Number StateGA

VIII. Authorized Official

Name: MS. CAROL REYNOLDS
Title or Position: PRESIDENT/CEO
Credential:
Phone: 404-786-4440