Provider Demographics
NPI:1164964003
Name:CREATIVE IMAGE PERSONAL CARE SERVICE LLC
Entity Type:Organization
Organization Name:CREATIVE IMAGE PERSONAL CARE SERVICE LLC
Other - Org Name:CREATIVE IMAGE RESPITE CARE SERVICE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:RENA
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-379-0238
Mailing Address - Street 1:216 FRENCH RD
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-9668
Mailing Address - Country:US
Mailing Address - Phone:662-379-0238
Mailing Address - Fax:662-887-8050
Practice Address - Street 1:503 HIGHWAY 82 E
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2317
Practice Address - Country:US
Practice Address - Phone:662-379-0238
Practice Address - Fax:662-887-8050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
311ZA0620X-ADULTCARE311ZA0620X
MS385H00000X-RESPITE385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home