MEDICARE: CREATIVE CARE SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	15709	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15709	OTHER	MN	SOCIAL WORKER LIC

General Provider Information

NPI Number	:	1568849768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE CARE SERVICES, LLC

Provider Business Mailing Address
First Line	:	4167 LYNDALE AVE N STE 301
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55412-1737
Country	:	US
Telephone Number	:	612-545-5290
Fax Number	:

Provider Business Practice Location Address
First Line	:	4167 LYNDALE AVE N STE 301
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55412-1737
Country	:	US
Telephone Number	:	612-545-5290
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	YER YANG
Credential	:
Telephone Number	:	612-545-5290

Provider Enumeration Date	:	04/27/2015
Last Update Date	:	04/27/2015

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