Provider Demographics
NPI:1033585526
Name:CROSSROADS YOUTH RANCH
Entity Type:Organization
Organization Name:CROSSROADS YOUTH RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-920-1084
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:PACOLET
Mailing Address - State:SC
Mailing Address - Zip Code:29372-0309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:344 FLEMMING ROAD
Practice Address - Street 2:
Practice Address - City:PACOLET
Practice Address - State:SC
Practice Address - Zip Code:29372-0000
Practice Address - Country:US
Practice Address - Phone:360-920-1084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health