Provider Demographics
NPI:1255127429
Name:ELITE CREATIVE CARE LLC
Entity type:Organization
Organization Name:ELITE CREATIVE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXUS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHABAZZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:804-651-4879
Mailing Address - Street 1:4316 KENMARE LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23234-3004
Mailing Address - Country:US
Mailing Address - Phone:804-651-4879
Mailing Address - Fax:
Practice Address - Street 1:6001 LAKESIDE AVE STE 20
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23228-5747
Practice Address - Country:US
Practice Address - Phone:407-803-1144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health