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General NPI Number Information
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NPI Number | 1548053754
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Entity Type | Organization
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Legal Business Name | CREEKSIDE CARE LLC
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Dates
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Enumeration Date | 05/28/2025
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Last Update Date | 05/28/2025
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Provider Practice Location Address
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Address Line | 222 6TH AVE W
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City | JEROME
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State | ID
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Zip | 83338-1834
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Country | US
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Telephone | 208-373-1424
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Fax |
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Provider Business Mailing Address
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Address Line | 4423 N 1600 E
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City | BUHL
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State | ID
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Zip | 83316-5326
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. RYAN DAVID BOWDEN
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Credential |
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Telephone | 801-319-0071
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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