Provident Group - Creekside Properties LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

Legal business name

PROVIDENT GROUP - CREEKSIDE PROPERTIES LLC

Practice address

4838 South Cobb Drive
Smyrna, GA 30080

Phone

(678) 710-1834

Fax

(678) 236-0374

NPI assigned

Jun 6, 2018

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Debra W. Lockwood

Title

President & Chief Financial Officer

Phone

(225) 766-3977

Specialties & licenses 3

Addresses

Other names 1

• Provident Village at Creekside Doing business as

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1528243200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1528243200000",
    "number": "1891287645",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5565 BANKERS AVENUE",
            "city": "BATON ROUGE",
            "state": "LA",
            "postal_code": "70808",
            "telephone_number": "225-766-3977",
            "fax_number": "225-766-3988"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4838 SOUTH COBB DRIVE",
            "city": "SMYRNA",
            "state": "GA",
            "postal_code": "30080",
            "telephone_number": "678-710-1834",
            "fax_number": "678-236-0374"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENT GROUP - CREEKSIDE PROPERTIES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-06-06",
        "last_updated": "2018-06-06",
        "status": "A",
        "authorized_official_last_name": "LOCKWOOD",
        "authorized_official_first_name": "DEBRA",
        "authorized_official_middle_name": "W.",
        "authorized_official_title_or_position": "PRESIDENT & CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "225-766-3977"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "311500000X",
            "taxonomy_group": "",
            "desc": "Alzheimer Center (Dementia Center)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "385H00000X",
            "taxonomy_group": "",
            "desc": "Respite Care",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Provident Village at Creekside",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Assisted Living Facility in Smyrna, GA
• Providers in Smyrna, GA by specialty
• Assisted Living Facility in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 6, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.