Healthcare Provider Details

I. General information

NPI: 1508440868
Provider Name (Legal Business Name): CROSSROADS SURGICAL ASSISTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 05/11/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5473 CARIBOU DR
FREDERICK CO
80504-5813
US

IV. Provider business mailing address

PO BOX 241
FREDERICK CO
80530-0241
US

V. Phone/Fax

Practice location:
  • Phone: 178-525-9469
  • Fax:
Mailing address:
  • Phone: 785-259-4694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MRS. THERESA LYNN HAINES
Title or Position: FIRST ASSISTANT/OWNER
Credential: CNOR RNFA
Phone: 785-259-4694