Provider Demographics
NPI:1578795324
Name:CREATIVE LIVING COMMUNITY SERVICES, LLC
Entity Type:Organization
Organization Name:CREATIVE LIVING COMMUNITY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-717-8806
Mailing Address - Street 1:3212 ARMISTEAD DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-6104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:853 PARAPET RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23323-2419
Practice Address - Country:US
Practice Address - Phone:757-717-8806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities