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General NPI Number Information
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NPI Number | 1285371021
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Entity Type | Organization
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Legal Business Name | CROSSROADS TELEMEDICINE PLLC
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Dates
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Enumeration Date | 05/13/2022
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Last Update Date | 05/13/2022
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Provider Practice Location Address
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Address Line | 3790 N BELLAFONT BLVD STE 1
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-5481
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Country | US
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Telephone | 479-439-0777
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Fax | 888-815-1613
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Provider Business Mailing Address
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Address Line | 3790 N BELLAFONT BLVD STE 1
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-5481
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Country | US
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Telephone | 479-439-0777
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Fax | 888-815-1613
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Authorized Official
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Title or Position | OWNER
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Name | THOMAS B DE MIRANDA
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Credential | MD
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Telephone | 479-285-1255
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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