Healthcare Provider Details

I. General information

NPI: 1700259173
Provider Name (Legal Business Name): CROSSROADS HEALTH & COSMETIC CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2015
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21764 OMEGA CT
GOSHEN IN
46528-7809
US

IV. Provider business mailing address

21764 OMEGA CT
GOSHEN IN
46528-7809
US

V. Phone/Fax

Practice location:
  • Phone: 574-891-4920
  • Fax: 574-891-4902
Mailing address:
  • Phone: 574-891-4920
  • Fax: 574-891-4902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number71002933A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number71002933A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71002933A
License Number StateIN

VIII. Authorized Official

Name: JOANNA ROTH
Title or Position: NURSE PRACTITIONER
Credential: ACNP-BC, FNP-C
Phone: 574-891-4920