Provider Demographics
NPI:1124380399
Name:CROSSROADS VISION CENTER, PC
Entity Type:Organization
Organization Name:CROSSROADS VISION CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDEL
Authorized Official - Middle Name:STERLING
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-692-2526
Mailing Address - Street 1:3200 SW 89TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7902
Mailing Address - Country:US
Mailing Address - Phone:405-692-2526
Mailing Address - Fax:405-692-2187
Practice Address - Street 1:3200 SW 89TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7902
Practice Address - Country:US
Practice Address - Phone:405-692-2526
Practice Address - Fax:405-692-2187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK923152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100761420BMedicaid