=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275614109
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROSSROAD - FORT WAYNE CHILDRENS HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2525 LAKE AVE
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46805-5407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-484-4153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2525 LAKE AVE
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46805-5407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-484-4153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | MR. JC DOLLAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 260-484-4153
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number | 7342602900837
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------