Healthcare Provider Details

I. General information

NPI: 1598017550
Provider Name (Legal Business Name): CREATIVE ENTERPRISES OF CLARENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N CENTER ST
CLARENCE MO
63437-1701
US

IV. Provider business mailing address

210 S SHELBY ST
CLARENCE MO
63437-2105
US

V. Phone/Fax

Practice location:
  • Phone: 660-699-2240
  • Fax: 660-699-2243
Mailing address:
  • Phone: 660-651-7350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name: JOHN D TIMMONS
Title or Position: OWNER
Credential:
Phone: 660-651-6961