Basic Information
Provider Information
NPI: 1366685364
EntityType: 2
ReplacementNPI:  
OrganizationName: CROSSROADS TREATMENT CENTERS
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
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Mailing Information
Address1: 436 SPRING GARDEN ST
Address2:  
City: GREENSBORO
State: NC
PostalCode: 274012734
CountryCode: US
TelephoneNumber: 3362729990
FaxNumber: 3365748378
Practice Location
Address1: 436 SPRING GARDEN ST
Address2:  
City: GREENSBORO
State: NC
PostalCode: 274012734
CountryCode: US
TelephoneNumber: 3362729990
FaxNumber: 3365748378
Other Information
ProviderEnumerationDate: 04/07/2009
LastUpdateDate: 12/17/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: LIGHT
AuthorizedOfficialFirstName: ARTIE
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CLINIC DIRECTOR
AuthorizedOfficialTelephone: 3362729990
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: TREATMENT CENTERS HOLDCO
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: C.S.A.C., C.C.S.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000XNC-10066-MNCY193400000X SINGLE SPECIALTY GROUPOther Service ProvidersSpecialist 

No ID Information.


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