Provider Demographics
NPI:1083882658
Name:CROSSROADS LIVING CENTER, INC.
Entity Type:Organization
Organization Name:CROSSROADS LIVING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:DUTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-532-7889
Mailing Address - Street 1:320 CERNON ST
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-4502
Mailing Address - Country:US
Mailing Address - Phone:707-449-9377
Mailing Address - Fax:
Practice Address - Street 1:325 HONEYSUCKLE DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-1124
Practice Address - Country:US
Practice Address - Phone:707-449-9377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities