Provider Demographics
NPI:1003257924
Name:CROSSROADS COMMUNITY HEALTH CLINIC, INC.
Entity Type:Organization
Organization Name:CROSSROADS COMMUNITY HEALTH CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LILLY-MARIE
Authorized Official - Middle Name:MAITA
Authorized Official - Last Name:BLECHER
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:575-776-7806
Mailing Address - Street 1:1337 GUSDORF RD
Mailing Address - Street 2:SUITE O
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6294
Mailing Address - Country:US
Mailing Address - Phone:575-776-7806
Mailing Address - Fax:
Practice Address - Street 1:1337 GUSDORF RD
Practice Address - Street 2:SUITE O
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6294
Practice Address - Country:US
Practice Address - Phone:575-776-7806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-08
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1102171100000X
NMMD2011-0528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1306090907OtherTYPE 1 NPI