Provider Demographics
NPI:1598089773
Name:CREEKWOOD TRAIL ADULT FOSTER CARE HOME
Entity Type:Organization
Organization Name:CREEKWOOD TRAIL ADULT FOSTER CARE HOME
Other - Org Name:CREEKWOOD TRAIL FAMILY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOME CARE PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-625-0869
Mailing Address - Street 1:10078 CREEKWOOD TRL
Mailing Address - Street 2:240 O'RILEY COURT
Mailing Address - City:DAVISBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48350-2058
Mailing Address - Country:US
Mailing Address - Phone:248-625-0869
Mailing Address - Fax:248-620-9403
Practice Address - Street 1:10078 CREEKWOOD TRAIL
Practice Address - Street 2:
Practice Address - City:DAVISBURG
Practice Address - State:MI
Practice Address - Zip Code:48350-2058
Practice Address - Country:US
Practice Address - Phone:248-625-0869
Practice Address - Fax:248-620-9403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS630277210302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization