Healthcare Provider Details

I. General information

NPI: 1619982410
Provider Name (Legal Business Name): CREEKWOOD PLACE NURSING & REHAB CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 12/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 BOYLES DR
RUSSELLVILLE KY
42276-8838
US

IV. Provider business mailing address

485 N KELLER RD SUITE 250
MAITLAND FL
32751-7503
US

V. Phone/Fax

Practice location:
  • Phone: 270-726-9049
  • Fax: 270-726-8706
Mailing address:
  • Phone: 407-975-3000
  • Fax: 407-975-3090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number90003948
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100299
License Number StateKY

VIII. Authorized Official

Name: MR. DAVID RODMAN
Title or Position: ASST SECRETARY
Credential:
Phone: 407-975-3011