Provider Demographics
NPI:1528243219
Name:CREATIVE CUSTOM LIVING, INC.
Entity type:Organization
Organization Name:CREATIVE CUSTOM LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALLRED
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:336-674-7751
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27313-0638
Mailing Address - Country:US
Mailing Address - Phone:336-674-7751
Mailing Address - Fax:336-674-6336
Practice Address - Street 1:6010 DAVIS MILL RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-9129
Practice Address - Country:US
Practice Address - Phone:336-674-7751
Practice Address - Fax:336-674-6336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-01
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-845261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health