Provider Demographics
NPI:1881819621
Name:CROSSROADS FOUNDATION
Entity Type:Organization
Organization Name:CROSSROADS FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DORA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-296-1151
Mailing Address - Street 1:3594 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4940
Mailing Address - Country:US
Mailing Address - Phone:619-296-1151
Mailing Address - Fax:619-255-6407
Practice Address - Street 1:3594 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4940
Practice Address - Country:US
Practice Address - Phone:619-296-1151
Practice Address - Fax:619-255-6407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA370002AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37-0001OtherSTATE PROVIDER CODE