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General NPI Number Information
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NPI Number | 1851848436
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Entity Type | Organization
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Legal Business Name | CROSSTOWN FAMILY CARE HOME, INC
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Dates
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Enumeration Date | 09/01/2016
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Last Update Date | 09/25/2017
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Provider Practice Location Address
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Address Line | 1850 SW MACKENZIE ST
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City | PORT ST LUCIE
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State | FL
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Zip | 34953-1329
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Country | US
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Telephone | 954-667-5616
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Fax | 772-333-2894
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Provider Business Mailing Address
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Address Line | 1850 SOUTHWEST MACKENZIE STREET
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City | PORT ST LUCIE
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State | FL
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Zip | 34953-1329
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Country | US
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Telephone | 954-667-5616
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Fax | 772-333-2894
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Authorized Official
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Title or Position | DIRECTOR
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Name | NELLIE JOHNSON
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Credential |
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Telephone | 954-667-5616
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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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 | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number |
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License Number State |
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