Provider Demographics
NPI:1104250406
Name:CREEKSIDE HEALTHCARE, LLC
Entity type:Organization
Organization Name:CREEKSIDE HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHEEHAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:423-618-1488
Mailing Address - Street 1:306 W DUE WEST AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-4511
Mailing Address - Country:US
Mailing Address - Phone:615-612-4499
Mailing Address - Fax:615-612-4498
Practice Address - Street 1:306 W DUE WEST AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-4511
Practice Address - Country:US
Practice Address - Phone:615-612-4499
Practice Address - Fax:615-612-4498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-23
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN445516Medicare Oscar/Certification