Provider Demographics
NPI:1932139169
Name:CROSSROADS HEALTH CLINIC, P.A.
Entity Type:Organization
Organization Name:CROSSROADS HEALTH CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCFALLS
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-286-2300
Mailing Address - Street 1:1801 S HARPER RD STE 7
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-6726
Mailing Address - Country:US
Mailing Address - Phone:662-286-2300
Mailing Address - Fax:662-286-7010
Practice Address - Street 1:1801 S HARPER RD STE 7
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-6726
Practice Address - Country:US
Practice Address - Phone:662-286-2300
Practice Address - Fax:662-286-7010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS258980261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00656871Medicaid
MSR582662OtherNURSE LICENSE #
MS0121943Medicaid
MSR582662OtherNURSE LICENSE #
MS500001787Medicare ID - Type UnspecifiedINDIVIDUAL MCARE #