=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346850708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROSSROADS TREATMENT CENTERS OF TENNESSEE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2020
-----------------------------------------------------
Last Update Date | 07/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 PERKINS LN
-----------------------------------------------------
City | JACKSBORO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37757-2833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-436-7266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 BEATTIE PL STE 810
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29601-2191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-436-7266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | RUPERT JAMES MCCORMAC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-805-6989
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------