Basic Information
| Provider Information | |||||||||
| NPI: | 1104581040 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CROSSROADS TREATMENT CENTERS OF TENNESSEE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 E BROAD ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008056989 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2605 S NONCONNAH BLVD | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381322144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008056989 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2021 | ||||||||
| LastUpdateDate: | 11/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | MCCORMAC | ||||||||
| AuthorizedOfficialFirstName: | RUPERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8008056989 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | IV | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM3000X | N | Ambulatory Health Care Facilities | Clinic/Center | Medically Fragile Intants and Children Day Care | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.