Provider Demographics
NPI:1891287645
Name:PROVIDENT GROUP - CREEKSIDE PROPERTIES LLC
Entity Type:Organization
Organization Name:PROVIDENT GROUP - CREEKSIDE PROPERTIES LLC
Other - Org Name:PROVIDENT VILLAGE AT CREEKSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:W
Authorized Official - Last Name:LOCKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-766-3977
Mailing Address - Street 1:5565 BANKERS AVENUE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808
Mailing Address - Country:US
Mailing Address - Phone:225-766-3977
Mailing Address - Fax:225-766-3988
Practice Address - Street 1:4838 SOUTH COBB DRIVE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080
Practice Address - Country:US
Practice Address - Phone:678-710-1834
Practice Address - Fax:678-236-0374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No385H00000XRespite Care FacilityRespite Care