Healthcare Provider Details

I. General information

NPI: 1013434976
Provider Name (Legal Business Name): CROSSROADS TREATMENT CENTER OF DAWSONVILLE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 DAWSON COMMONS CIR STE 410
DAWSONVILLE GA
30534-6269
US

IV. Provider business mailing address

200 E BROAD ST STE 300
GREENVILLE SC
29601-2891
US

V. Phone/Fax

Practice location:
  • Phone: 800-805-6989
  • Fax: 864-558-8511
Mailing address:
  • Phone: 800-805-6989
  • Fax: 864-558-8511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. RUPERT MCCORMAC
Title or Position: PRESIDENT
Credential: MD
Phone: 800-805-6989