=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194343046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREEKSIDE PLACE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2020
-----------------------------------------------------
Last Update Date | 07/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7251 N BRIARCLIFF KNOLL DR
-----------------------------------------------------
City | WEST BLOOMFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48322-4049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-327-5484
-----------------------------------------------------
Fax | 248-250-5999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2995 WEIDEMANN DR
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48348-1249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-346-4515
-----------------------------------------------------
Fax | 248-250-5999
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | PUJA BORSO
-----------------------------------------------------
Credential | OTR/L, CLT, CAPS
-----------------------------------------------------
Telephone | 248-346-4515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------