Healthcare Provider Details

I. General information

NPI: 1578006433
Provider Name (Legal Business Name): CROSSROADS TREATMENT CENTER OF COLUMBIA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 BLUFF RD
COLUMBIA SC
29201-4809
US

IV. Provider business mailing address

PO BOX 749057
ATLANTA GA
30374-9057
US

V. Phone/Fax

Practice location:
  • Phone: 803-733-5855
  • Fax:
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 State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RUPERT J. MCCORMAC IV
Title or Position: CEO
Credential: M.D.
Phone: 800-805-6989