Provider Demographics
NPI:1114262045
Name:CREATIVE LIFE
Entity Type:Organization
Organization Name:CREATIVE LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ORLANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-291-5863
Mailing Address - Street 1:2443 N 37TH WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-2219
Mailing Address - Country:US
Mailing Address - Phone:602-291-5863
Mailing Address - Fax:
Practice Address - Street 1:2443 N 37TH WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-2219
Practice Address - Country:US
Practice Address - Phone:602-291-5863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVX251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management