Basic Information
| Provider Information | |||||||||
| NPI: | 1639744063 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CROSSROADS TREATMENT CENTER OF GREENSBORO, PC | ||||||||
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| OtherOrganizationName: | CROSSROADS TREATMENT CENTER OF GREENSBORO (LAB) | ||||||||
| 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: | 2706 N CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274053657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008056989 | ||||||||
| FaxNumber: | 8645588511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2021 | ||||||||
| LastUpdateDate: | 06/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | MCCORMAC | ||||||||
| AuthorizedOfficialFirstName: | RUPERT | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8008056989 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CROSSROADS TREATMENT CENTER OF GREENSBORO, PC | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 34D2083457 | 01 | NC | CLIA | OTHER |