Basic Information
| Provider Information | |||||||||
| NPI: | 1528432978 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CREEKSIDE HEALTH HOLDINGS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CREEKSIDE HEALTH AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 N PANTHER AVE | ||||||||
| Address2: | |||||||||
| City: | YELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726879313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665661640 | ||||||||
| FaxNumber: | 8704496695 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 N PANTHER AVE | ||||||||
| Address2: | |||||||||
| City: | YELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726879313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665661640 | ||||||||
| FaxNumber: | 8704496695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2015 | ||||||||
| LastUpdateDate: | 02/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | SCHWARTZ | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2016351195 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1097 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 211198311 | 05 | AR | MEDICAID |