Provider Demographics
NPI:1427582725
Name:THE LAKES AT BLACK CREEK
Entity Type:Organization
Organization Name:THE LAKES AT BLACK CREEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-768-5871
Mailing Address - Street 1:7260 OBYRNES FERRY RD
Mailing Address - Street 2:
Mailing Address - City:COPPEROPOLIS
Mailing Address - State:CA
Mailing Address - Zip Code:95228-9761
Mailing Address - Country:US
Mailing Address - Phone:209-325-8535
Mailing Address - Fax:
Practice Address - Street 1:88 SANGUINETTI CT
Practice Address - Street 2:
Practice Address - City:COPPEROPOLIS
Practice Address - State:CA
Practice Address - Zip Code:95228-9459
Practice Address - Country:US
Practice Address - Phone:209-325-8506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE LAKES TREATMENT CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-13
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA050005BP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility