=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366102410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREATIONS OF CARE HOME CARE LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2021
-----------------------------------------------------
Last Update Date | 05/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2434 PASS RD # D-13
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39531-2121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-641-7561
-----------------------------------------------------
Fax | 844-836-2419
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 930 JEFFERSON DR
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39507-3816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-641-7561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RENEE GUSTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 228-641-7561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246RP1900X
-----------------------------------------------------
Taxonomy Name | Phlebotomy Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------