Provider Demographics
NPI:1700108990
Name:CREATIVE ENTERPRISES OF CLARENCE
Entity Type:Organization
Organization Name:CREATIVE ENTERPRISES OF CLARENCE
Other - Org Name:CAROL TIMMONS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:TIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-651-6961
Mailing Address - Street 1:210 S SHELBY ST
Mailing Address - Street 2:
Mailing Address - City:CLARENCE
Mailing Address - State:MO
Mailing Address - Zip Code:63437-2105
Mailing Address - Country:US
Mailing Address - Phone:660-651-6961
Mailing Address - Fax:
Practice Address - Street 1:101 N CENTER ST
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:MO
Practice Address - Zip Code:63437-1701
Practice Address - Country:US
Practice Address - Phone:660-699-2240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO092882261QR1300X, 363LF0000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicare Oscar/Certification