Provider Demographics
NPI:1942958111
Name:CROSSOVER COMMUNITY IMPACT, INC.
Entity Type:Organization
Organization Name:CROSSOVER COMMUNITY IMPACT, INC.
Other - Org Name:CROSSOVER HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-330-9645
Mailing Address - Street 1:940 E 36TH ST N
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-1953
Mailing Address - Country:US
Mailing Address - Phone:918-398-9460
Mailing Address - Fax:
Practice Address - Street 1:5635 N MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74126-6409
Practice Address - Country:US
Practice Address - Phone:918-398-9460
Practice Address - Fax:918-992-2822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200514040BMedicaid