Provider Demographics
NPI:1982988226
Name:CREEKSIDE ASSISTED LIVING LLC
Entity type:Organization
Organization Name:CREEKSIDE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RILEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-648-6887
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:CLARKTON
Mailing Address - State:NC
Mailing Address - Zip Code:28433-0847
Mailing Address - Country:US
Mailing Address - Phone:910-648-6887
Mailing Address - Fax:910-648-6888
Practice Address - Street 1:1124 CEDAR CREEK RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28312-6544
Practice Address - Country:US
Practice Address - Phone:910-323-8212
Practice Address - Fax:910-323-2159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-026-059310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility