1184102709 NPI number — CROSSROADS EXTENSION

Table of content: (NPI 1184102709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184102709 NPI number — CROSSROADS EXTENSION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROSSROADS EXTENSION
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:
1184102709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2002 E OSBORN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85016-7236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-263-5242
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
244 N EXTENSION RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85201-6300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-263-5242
Provider Business Practice Location Address Fax Number:
602-595-4434
Provider Enumeration Date:
08/06/2018

Additional Information

Authorized Official

Authorized Official Last Name:
RILEY
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
COMPLIANCE OFFICER
Authorized Official Telephone Number:
602-263-5242

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  BH-5467 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 397764 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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