Provider Demographics
NPI:1194343046
Name:CREEKSIDE PLACE, INC.
Entity type:Organization
Organization Name:CREEKSIDE PLACE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PUJA
Authorized Official - Middle Name:
Authorized Official - Last Name:BORSO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L, CLT, CAPS
Authorized Official - Phone:248-346-4515
Mailing Address - Street 1:2995 WEIDEMANN DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-1249
Mailing Address - Country:US
Mailing Address - Phone:248-346-4515
Mailing Address - Fax:248-250-5999
Practice Address - Street 1:7251 N BRIARCLIFF KNOLL DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4049
Practice Address - Country:US
Practice Address - Phone:877-327-5484
Practice Address - Fax:248-250-5999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAS630397523OtherLICENSE NUMBER