Provider Demographics
NPI:1265704498
Name:CROSSROADS REHABILITATION SERVICES
Entity type:Organization
Organization Name:CROSSROADS REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L, CHT
Authorized Official - Phone:662-534-4445
Mailing Address - Street 1:206B OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3115
Mailing Address - Country:US
Mailing Address - Phone:662-534-4445
Mailing Address - Fax:662-534-9449
Practice Address - Street 1:206B OXFORD RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3115
Practice Address - Country:US
Practice Address - Phone:662-534-4445
Practice Address - Fax:662-534-9449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09198/11.1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01874080Medicaid