MEDICARE: CROSSOVER HEALTH MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1164150835
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSOVER HEALTH MEDICAL GROUP

Provider Business Mailing Address
First Line	:	101 W AVENIDA VISTA HERMOSA STE 120
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-7707
Country	:	US
Telephone Number	:	714-925-4054
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 DEXTER AVE N
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98109-3517
Country	:	US
Telephone Number	:	949-891-0328
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS SPECIALIST
Name	:	ANGIE SAKIOKA
Credential	:
Telephone Number	:	949-891-0228

Provider Enumeration Date	:	08/10/2022
Last Update Date	:	08/10/2022

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