Basic Information
| Provider Information | |||||||||
| NPI: | 1174040034 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CROSSROADS TREATMENT CENTER OF NORTHERN KENTUCKY, PSC | ||||||||
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| OtherOrganizationName: | CROSSROADS TREATMENT CENTER OF NORTHERN KENTUCKY; CROSSROADS TREATMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 E BROAD ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008056989 | ||||||||
| FaxNumber: | 8645588511 | ||||||||
| Practice Location | |||||||||
| Address1: | 1974 WALTON NICHOLSON PIKE | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410517906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593595404 | ||||||||
| FaxNumber: | 8593590739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2017 | ||||||||
| LastUpdateDate: | 06/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | MCCORMAC | ||||||||
| AuthorizedOfficialFirstName: | RUPERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8008056989 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QM2800X | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 810538 | 01 | KY | STATE LICENSE | OTHER |