Provider Demographics
NPI:1003273483
Name:CROSSROAD AT NORTHGLENN, ALF
Entity Type:Organization
Organization Name:CROSSROAD AT NORTHGLENN, ALF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSHNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-774-7700
Mailing Address - Street 1:990 RESERVE DR STE 240
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-1391
Mailing Address - Country:US
Mailing Address - Phone:916-774-7700
Mailing Address - Fax:916-774-7701
Practice Address - Street 1:451 MALLEY DR
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80233-2024
Practice Address - Country:US
Practice Address - Phone:303-252-1118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MANAGEMENT SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2304MZ310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03585280Medicaid