Healthcare Provider Details

I. General information

NPI: 1295028694
Provider Name (Legal Business Name): CROSSROADS HEALING ARTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 PARKWAY AVE SUITE C
ELKHART IN
46516-9326
US

IV. Provider business mailing address

1004 PARKWAY AVE SUITE C
ELKHART IN
46516-9326
US

V. Phone/Fax

Practice location:
  • Phone: 574-294-1883
  • Fax: 574-295-1749
Mailing address:
  • Phone: 574-294-1883
  • Fax: 574-295-1749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1067015A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number02002929A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number71001272
License Number StateIN

VIII. Authorized Official

Name: MS. KELLY J BOYER
Title or Position: NURSE PRACTITIONER/OWNER
Credential: WHCNP
Phone: 574-294-1883