Provider Demographics
NPI:1184102709
Name:CROSSROADS EXTENSION
Entity type:Organization
Organization Name:CROSSROADS EXTENSION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
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 1:244 N EXTENSION RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-6300
Practice Address - Country:US
Practice Address - Phone:602-263-5242
Practice Address - Fax:602-595-4434
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSSROADS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-06
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-5467251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ397764Medicaid