Provider Demographics
NPI:1942583125
Name:CREATIVE COMMUNITY LIVING SERVICES
Entity Type:Organization
Organization Name:CREATIVE COMMUNITY LIVING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-440-2411
Mailing Address - Street 1:1201 LEGACY DR
Mailing Address - Street 2:1913
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023
Mailing Address - Country:US
Mailing Address - Phone:214-440-2411
Mailing Address - Fax:214-440-2411
Practice Address - Street 1:1201 LEGACY DR
Practice Address - Street 2:1913
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75023
Practice Address - Country:US
Practice Address - Phone:214-440-2411
Practice Address - Fax:214-440-2411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness