Provider Demographics
NPI:1083936157
Name:CROSSROADS COMMUNITY SOURCE
Entity Type:Organization
Organization Name:CROSSROADS COMMUNITY SOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:478-988-1294
Mailing Address - Street 1:1203 BALL ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-2501
Mailing Address - Country:US
Mailing Address - Phone:478-988-1294
Mailing Address - Fax:478-988-1193
Practice Address - Street 1:1203 BALL ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-2501
Practice Address - Country:US
Practice Address - Phone:478-988-1294
Practice Address - Fax:478-988-1193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management