Provider Demographics
NPI:1528581691
Name:CROSSROADS, INC. RED MOUNTAIN
Entity Type:Organization
Organization Name:CROSSROADS, INC. RED MOUNTAIN
Other - Org Name:RED MOUNTAIN SABG
Other - Org Type:Other Name
Authorized Official - Title/Position:CLAIMS SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-263-5242
Mailing Address - Street 1:2002 E OSBORN RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7236
Mailing Address - Country:US
Mailing Address - Phone:602-263-5242
Mailing Address - Fax:
Practice Address - Street 1:143 S CENTER ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-1307
Practice Address - Country:US
Practice Address - Phone:602-730-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSSROADS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-20
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ252069Medicaid