Healthcare Provider Details

I. General information

NPI: 1699715045
Provider Name (Legal Business Name): CROSSROADS HOSPICE OF ATLANTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1957 LAKESIDE PKWY STE 500
TUCKER GA
30084-5859
US

IV. Provider business mailing address

10810 E 45TH ST SUITE 300
TULSA OK
74146-3818
US

V. Phone/Fax

Practice location:
  • Phone: 770-270-9898
  • Fax: 770-270-9896
Mailing address:
  • Phone: 918-627-6846
  • Fax: 918-627-6856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number0200515330
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CLAYTON LEE FARMER
Title or Position: CFO/COO
Credential:
Phone: 918-627-6846