Provider Demographics
NPI:1851848436
Name:CROSSTOWN FAMILY CARE HOME, INC
Entity Type:Organization
Organization Name:CROSSTOWN FAMILY CARE HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-667-5616
Mailing Address - Street 1:1850 SOUTHWEST MACKENZIE STREET
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1329
Mailing Address - Country:US
Mailing Address - Phone:954-667-5616
Mailing Address - Fax:772-333-2894
Practice Address - Street 1:1850 SW MACKENZIE ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1329
Practice Address - Country:US
Practice Address - Phone:954-667-5616
Practice Address - Fax:772-333-2894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No251S00000XAgenciesCommunity/Behavioral Health
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL678513Medicaid