1174072482 NPI number — CROSSROADS 1010 LLC

Table of content: (NPI 1174072482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174072482 NPI number — CROSSROADS 1010 LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROSSROADS 1010 LLC
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:
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:
1174072482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BO 1012
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANTLERS
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-271-7080
Provider Business Mailing Address Fax Number:
580-298-2081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
193908 US HWY 271
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANTLERS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-271-7080
Provider Business Practice Location Address Fax Number:
580-298-2081
Provider Enumeration Date:
09/27/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GRIFFIN
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
580-317-7002

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)

  • Identifier: 200734990A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com