Provider Demographics
NPI:1841612215
Name:COLLEGE LAKES
Entity Type:Organization
Organization Name:COLLEGE LAKES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:GIOVANNI
Authorized Official - Last Name:CREECY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-257-6406
Mailing Address - Street 1:5104 FLATROCK DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311
Mailing Address - Country:US
Mailing Address - Phone:910-257-6406
Mailing Address - Fax:
Practice Address - Street 1:5104 FLATROCK DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311
Practice Address - Country:US
Practice Address - Phone:910-488-6323
Practice Address - Fax:910-223-2180
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHINELIGHT, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-20
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-047-133320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418071Medicaid