Provider Demographics
NPI:1275614109
Name:CROSSROAD - FORT WAYNE CHILDRENS HOME
Entity Type:Organization
Organization Name:CROSSROAD - FORT WAYNE CHILDRENS HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JC
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLLAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-484-4153
Mailing Address - Street 1:2525 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5407
Mailing Address - Country:US
Mailing Address - Phone:260-484-4153
Mailing Address - Fax:
Practice Address - Street 1:2525 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5407
Practice Address - Country:US
Practice Address - Phone:260-484-4153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN7342602900837261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health