Provider Demographics
NPI:1356700025
Name:MYSTIC CREEK, LLC
Entity type:Organization
Organization Name:MYSTIC CREEK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-538-3781
Mailing Address - Street 1:17969 WILSON SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-8588
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12489 STATE HIGHWAY 56
Practice Address - Street 2:
Practice Address - City:VIOLA
Practice Address - State:WI
Practice Address - Zip Code:54664-8914
Practice Address - Country:US
Practice Address - Phone:608-538-3781
Practice Address - Fax:608-538-3782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities