Provider Demographics
NPI:1255602215
Name:CREATIVE LEARNING INSTITUTE, INC.
Entity type:Organization
Organization Name:CREATIVE LEARNING INSTITUTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-704-5021
Mailing Address - Street 1:1601 E TUCKER ST
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-1639
Mailing Address - Country:US
Mailing Address - Phone:310-704-5021
Mailing Address - Fax:310-438-1707
Practice Address - Street 1:1702 N WILMINGTON AVE
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90222-3419
Practice Address - Country:US
Practice Address - Phone:310-704-5021
Practice Address - Fax:310-438-1707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage