Provider Demographics
NPI:1235311994
Name:CREOLIA'S HOUSE LLC
Entity Type:Organization
Organization Name:CREOLIA'S HOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LATONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-634-0593
Mailing Address - Street 1:1074 CANDY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-1631
Mailing Address - Country:US
Mailing Address - Phone:336-634-0593
Mailing Address - Fax:336-634-0593
Practice Address - Street 1:627 LAKE ST
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-4323
Practice Address - Country:US
Practice Address - Phone:336-635-4999
Practice Address - Fax:336-635-4999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children