Provider Demographics
NPI:1205876653
Name:CROSSROADS HOSPICE OF NORTHEAST
Entity type:Organization
Organization Name:CROSSROADS HOSPICE OF NORTHEAST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-627-6846
Mailing Address - Street 1:10810 E 45TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-3818
Mailing Address - Country:US
Mailing Address - Phone:918-627-6846
Mailing Address - Fax:918-627-6856
Practice Address - Street 1:3743 BOETTLER OAKS DR STE E
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685-6227
Practice Address - Country:US
Practice Address - Phone:330-342-3328
Practice Address - Fax:330-342-3354
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARREFOUR ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-07
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QH0002X
OH0147HSP251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251G00000XAgenciesHospice Care, Community Based
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2653641Medicaid
361625Medicare Oscar/Certification