1265884969 NPI number — CROSSROADS COMMUNITY SUPPORTED HEALTHCARE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265884969 NPI number — CROSSROADS COMMUNITY SUPPORTED HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROSSROADS COMMUNITY SUPPORTED HEALTHCARE
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:
Provider Other Organization Name Type Code:
6
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:
1265884969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1320 SOUTH SOLANO DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88001-5672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-312-6569
Provider Business Mailing Address Fax Number:
575-502-5013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1320 S SOLANO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88001-3781
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-312-6569
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/06/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BEMIS
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
575-312-6569

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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