Basic Information
| Provider Information | |||||||||
| NPI: | 1437138070 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CROSSROADS HOME CARE SERVICES, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEDERI CARETENDERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51266 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705051266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372331307 | ||||||||
| FaxNumber: | 3374434154 | ||||||||
| Practice Location | |||||||||
| Address1: | 4111 NORTH TOWER PLACE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | MT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628646566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189881840 | ||||||||
| FaxNumber: | 6189888623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GACHASSIN | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 3732331307 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 1008390 | IL | N | Agencies | Home Health | 251E00000X | 1011103 | MO | Y | Agencies | Home Health |
No ID Information.