Provider Demographics
NPI:1871594846
Name:CREATIVE LIFESTYLES MANAGEMENT PROG
Entity type:Organization
Organization Name:CREATIVE LIFESTYLES MANAGEMENT PROG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHIARAMONTE
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT
Authorized Official - Phone:301-877-4530
Mailing Address - Street 1:7503 SURRATTS ROAD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-3358
Mailing Address - Country:US
Mailing Address - Phone:301-870-7001
Mailing Address - Fax:301-870-6697
Practice Address - Street 1:7501 SURRATTS ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3358
Practice Address - Country:US
Practice Address - Phone:301-877-4616
Practice Address - Fax:301-877-4355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207RP1001X
207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD100650Medicare PIN