Provider Demographics
NPI:1073051264
Name:CREEKSIDE MANOR
Entity Type:Organization
Organization Name:CREEKSIDE MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:CHAFFEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-796-6131
Mailing Address - Street 1:17460 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-9554
Mailing Address - Country:US
Mailing Address - Phone:231-796-6131
Mailing Address - Fax:
Practice Address - Street 1:17460 12 MILE RD
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-9554
Practice Address - Country:US
Practice Address - Phone:231-796-6131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM540070004302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization