Basic Information
Provider Information | |||||||||
NPI: | 1043715329 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CROSSROADS TREATMENT CENTER OF WEST MEMPHIS, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 55 BEATTIE PL STE 810 | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296012191 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8645273145 | ||||||||
FaxNumber: | 8649900653 | ||||||||
Practice Location | |||||||||
Address1: | 103 S AVALON ST | ||||||||
Address2: |   | ||||||||
City: | WEST MEMPHIS | ||||||||
State: | AR | ||||||||
PostalCode: | 72301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703944307 | ||||||||
FaxNumber: | 8703949936 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2018 | ||||||||
LastUpdateDate: | 08/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCORMAC | ||||||||
AuthorizedOfficialFirstName: | RUPERT | ||||||||
AuthorizedOfficialMiddleName: | JAMES | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8645273145 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   | AR | N |   | Agencies | Community/Behavioral Health |   | 261QM2800X |   | AR | N |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QR0405X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.