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General NPI Number Information
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NPI Number | 1528243219
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Entity Type | Organization
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Legal Business Name | CREATIVE CUSTOM LIVING, INC.
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Dates
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Enumeration Date | 01/01/2008
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Last Update Date | 01/02/2008
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Provider Practice Location Address
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Address Line | 6010 DAVIS MILL RD
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City | GREENSBORO
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State | NC
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Zip | 27406-9129
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Country | US
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Telephone | 336-674-7751
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Fax | 336-674-6336
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Provider Business Mailing Address
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Address Line | PO BOX 638
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City | PLEASANT GARDEN
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State | NC
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Zip | 27313-0638
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Country | US
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Telephone | 336-674-7751
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Fax | 336-674-6336
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. JERRY A. ALLRED SR.
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Credential |
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Telephone | 336-674-7751
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | MHL-041-845
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License Number State | NC
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