1104155944 NPI number — CREATIVE MOTION, INC

Table of content: (NPI 1104155944)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104155944 NPI number — CREATIVE MOTION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREATIVE MOTION, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CREATIVE MOTION PEDIATRIC THERAPY
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104155944
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5907 W. MARSHALL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-759-6500
Provider Business Mailing Address Fax Number:
903-759-6500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5907 W. MARSHALL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-759-6500
Provider Business Practice Location Address Fax Number:
903-759-6500
Provider Enumeration Date:
12/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BELL
Authorized Official First Name:
WANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
903-759-6500

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  1110948 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 1110948 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X , with the licence number: 105205 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0631053 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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