Provider Demographics
NPI:1053853192
Name:CREATIVE CHILD CARE, INC.
Entity Type:Organization
Organization Name:CREATIVE CHILD CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:EISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-941-9100
Mailing Address - Street 1:600 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-3029
Mailing Address - Country:US
Mailing Address - Phone:209-941-9100
Mailing Address - Fax:209-941-9110
Practice Address - Street 1:4719 QUAIL LAKES DR
Practice Address - Street 2:G-237
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5267
Practice Address - Country:US
Practice Address - Phone:209-941-9100
Practice Address - Fax:209-941-9110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA39155742Medicaid