Basic Information
| Provider Information | |||||||||
| NPI: | 1023360526 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CREEKSIDE HEALTH AND REHABILITATION, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1423 CLARKVIEW RD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212092134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104272700 | ||||||||
| FaxNumber: | 4148155558 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 N PANTHER AVE | ||||||||
| Address2: | |||||||||
| City: | YELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726879313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704494201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2012 | ||||||||
| LastUpdateDate: | 06/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | REYNOLDS | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4105138738 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 193308311 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 193308311 | 05 | AR | MEDICAID |