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General NPI Number Information
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NPI Number | 1700541984
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Entity Type | Organization
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Legal Business Name | CREEKSIDE FAMILY CARE LLC
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Dates
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Enumeration Date | 11/03/2021
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Last Update Date | 11/03/2021
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Provider Practice Location Address
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Address Line | 1345 W MASON ST STE 202
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City | GREEN BAY
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State | WI
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Zip | 54303-2049
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Country | US
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Telephone | 920-301-3907
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Fax | 920-391-5180
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Provider Business Mailing Address
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Address Line | 1345 W MASON ST STE 202
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City | GREEN BAY
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State | WI
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Zip | 54303-2049
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Country | US
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Telephone | 920-301-3907
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Fax | 920-391-5180
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Authorized Official
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Title or Position | OWNER/ADMINISTRATOR
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Name | DAQUET REED
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Credential |
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Telephone | 920-301-3907
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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