Provider Demographics
NPI:1447430376
Name:CREATIVE LIFESTYLES MANAGEMENT PROG
Entity Type:Organization
Organization Name:CREATIVE LIFESTYLES MANAGEMENT PROG
Other - Org Name:LABORATORY FOR SLEEP DISORDERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-877-4541
Mailing Address - Street 1:7503 SURRATTS ROAD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-3358
Mailing Address - Country:US
Mailing Address - Phone:301-870-7001
Mailing Address - Fax:301-870-6697
Practice Address - Street 1:10 ST. PATRICKS DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-3500
Practice Address - Country:US
Practice Address - Phone:301-877-4600
Practice Address - Fax:301-870-5747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD020MMedicare PIN