Healthcare Provider Details

I. General information

NPI: 1043715329
Provider Name (Legal Business Name): CROSSROADS TREATMENT CENTER OF WEST MEMPHIS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S AVALON ST
WEST MEMPHIS AR
72301
US

IV. Provider business mailing address

55 BEATTIE PL STE 810
GREENVILLE SC
29601-2191
US

V. Phone/Fax

Practice location:
  • Phone: 870-394-4307
  • Fax: 870-394-9936
Mailing address:
  • Phone: 864-527-3145
  • Fax: 864-990-0653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateAR

VIII. Authorized Official

Name: RUPERT JAMES MCCORMAC
Title or Position: PRESIDENT
Credential:
Phone: 864-527-3145