=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861775058
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROSSROADS REHABILITATION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2011
-----------------------------------------------------
Last Update Date | 09/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 W MAIN ST
-----------------------------------------------------
City | HOMER
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71040-4435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-927-4987
-----------------------------------------------------
Fax | 318-927-4987
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 N SERVICE RD E PMB 207
-----------------------------------------------------
City | RUSTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71270-2805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-927-4987
-----------------------------------------------------
Fax | 318-927-4987
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEVEN R GRAYSON
-----------------------------------------------------
Credential | OTR
-----------------------------------------------------
Telephone | 318-927-4987
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------