=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285599431
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROSSROADS TREATMENT CENTERS OF TENNESSEE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2025
-----------------------------------------------------
Last Update Date | 12/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3114 BROWNS MILL RD
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-1417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-805-6989
-----------------------------------------------------
Fax | 864-558-8511
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 749057
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-9057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-805-6989
-----------------------------------------------------
Fax | 864-558-8511
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | RUPERT MCCORMAC IV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-805-6989
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------