Provider Demographics
NPI:1548614803
Name:CREEKSIDE MANOR ASSISTED LIVING, INC.
Entity Type:Organization
Organization Name:CREEKSIDE MANOR ASSISTED LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-401-8930
Mailing Address - Street 1:PO BOX 4150
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-4150
Mailing Address - Country:US
Mailing Address - Phone:662-322-4636
Mailing Address - Fax:662-840-3311
Practice Address - Street 1:200 KNIGHT DR
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866-9182
Practice Address - Country:US
Practice Address - Phone:662-869-7009
Practice Address - Fax:662-869-7891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS751310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility