Healthcare Provider Details

I. General information

NPI: 1104352517
Provider Name (Legal Business Name): CREATIVE MINDS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2017
Last Update Date: 05/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14089 VINTAGE DR SW
PORT ORCHARD WA
98367-7394
US

IV. Provider business mailing address

14089 VINTAGE DR SW
PORT ORCHARD WA
98367-7394
US

V. Phone/Fax

Practice location:
  • Phone: 360-551-2440
  • Fax:
Mailing address:
  • Phone: 360-551-2440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. ROGER ALAN NORDLANDER
Title or Position: PRESIDENT
Credential:
Phone: 360-551-2440