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General NPI Number Information
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NPI Number | 1538675004
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Entity Type | Organization
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Legal Business Name | CROSSROADS WELLNESS GROUP, LLC
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Dates
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Enumeration Date | 12/20/2017
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Last Update Date | 10/30/2019
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Provider Practice Location Address
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Address Line | 4200 SW 54TH CT
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City | FORT LAUDERDALE
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State | FL
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Zip | 33314-6726
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Country | US
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Telephone | 954-999-3458
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Fax |
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Provider Business Mailing Address
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Address Line | 11571 NW 20TH CT
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City | PLANTATION
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State | FL
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Zip | 33323-2007
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JASON LUCAS
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Credential | DC
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Telephone | 954-999-3458
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH10147
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License Number State | FL
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