Basic Information
| Provider Information | |||||||||
| NPI: | 1457359838 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CROSSROADS REHABILITATION CENTER, INC. | ||||||||
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| OtherOrganizationName: | EASTER SEALS CROSSROADS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4740 KINGSWAY DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462051521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174661000 | ||||||||
| FaxNumber: | 3174662000 | ||||||||
| Practice Location | |||||||||
| Address1: | 4740 KINGSWAY DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462051521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174661000 | ||||||||
| FaxNumber: | 3174662000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 07/30/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SANDY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | PATRICK | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3174662015 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XR0403X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Driving and Community Mobility | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 100462120 | 05 | IN | MEDICAID |