Provider Demographics
NPI:1518458249
Name:CREATE IT KIDS CLUB, LLC.
Entity Type:Organization
Organization Name:CREATE IT KIDS CLUB, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TAMEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-235-4333
Mailing Address - Street 1:1425 MARKET BLVD STE 530-251
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-6708
Mailing Address - Country:US
Mailing Address - Phone:678-235-4333
Mailing Address - Fax:
Practice Address - Street 1:1425 MARKET BLVD STE 530-251
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-6708
Practice Address - Country:US
Practice Address - Phone:678-235-4333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No385HR2050XRespite Care FacilityRespite CareRespite Care Camp