Provider Demographics
NPI:1205938412
Name:CROSSROADS SUPPORT SERVICES, INC
Entity type:Organization
Organization Name:CROSSROADS SUPPORT SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-736-9242
Mailing Address - Street 1:PO BOX 251
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27533-0251
Mailing Address - Country:US
Mailing Address - Phone:919-736-9242
Mailing Address - Fax:919-736-9299
Practice Address - Street 1:1316 WAYNE MEMORIAL DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-2253
Practice Address - Country:US
Practice Address - Phone:919-736-9242
Practice Address - Fax:919-736-9299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC 1678374U00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300562Medicaid
NC6600650Medicaid
NC3408924Medicaid
NC7211500Medicaid