Provider Demographics
NPI:1043815202
Name:CREEKSIDE RECOVERY RESIDENCES, LLC
Entity Type:Organization
Organization Name:CREEKSIDE RECOVERY RESIDENCES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CARTER
Authorized Official - Middle Name:
Authorized Official - Last Name:POPE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:404-333-2277
Mailing Address - Street 1:2940 MABRY RD NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-2605
Mailing Address - Country:US
Mailing Address - Phone:404-333-2277
Mailing Address - Fax:
Practice Address - Street 1:2940 MABRY RD NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-2605
Practice Address - Country:US
Practice Address - Phone:404-333-2277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management