Healthcare Provider Details

I. General information

NPI: 1154517480
Provider Name (Legal Business Name): CREATIVE LIVING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4748 STANTONSBURG RD
GREENVILLE NC
27834-4794
US

IV. Provider business mailing address

PO BOX 948
GREENVILLE NC
27835-0948
US

V. Phone/Fax

Practice location:
  • Phone: 252-757-0147
  • Fax: 252-757-0147
Mailing address:
  • Phone: 252-757-0147
  • Fax: 252-757-0147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHRISTINA HARDY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 252-757-0147