Provider Demographics
NPI:1871546895
Name:CREATIVE WELLNESS LLC
Entity type:Organization
Organization Name:CREATIVE WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DIANNE
Authorized Official - Last Name:CORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-427-7200
Mailing Address - Street 1:18947 125TH AVE N
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33478-3792
Mailing Address - Country:US
Mailing Address - Phone:561-427-7200
Mailing Address - Fax:561-427-7203
Practice Address - Street 1:18947 125TH AVE N
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33478-3792
Practice Address - Country:US
Practice Address - Phone:561-427-7200
Practice Address - Fax:561-427-7203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY915KOtherBLUE CROSS BLUE SHIELD FL
FLDD4181OtherRAILROAD MEDICARE
FLDD4181OtherRAILROAD MEDICARE