MEDICARE: PARK CREEK CENTER 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1912860750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK CREEK CENTER LLC

Provider Business Mailing Address
First Line	:	10064 N CHURCH DR
Second Line	:
City	:	PARMA HEIGHTS
State	:	OH
Zip	:	44130-4066
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10064 N CHURCH DR
Second Line	:
City	:	PARMA HEIGHTS
State	:	OH
Zip	:	44130-4066
Country	:	US
Telephone Number	:	917-544-4713
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	AVI LUSTIG
Credential	:
Telephone Number	:	917-544-4713

Provider Enumeration Date	:	12/08/2025
Last Update Date	:	12/08/2025

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Directions to “PARK CREEK CENTER LLC ” Practice Location

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