MEDICARE: CROSSPEAKS SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3140N1450X	Pediatric Skilled Nursing Facility	550000017	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HA0890	OTHER	CA	ALTA CALIFORNIA REGIONAL CENTER
2	EPSP00110	OTHER	CA	MEDI-CAL PROVIDER NUMBER

General Provider Information

NPI Number	:	1053463752
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSPEAKS SERVICES, INC.

Provider Business Mailing Address
First Line	:	1121 MAIDU DR
Second Line	:
City	:	AUBURN
State	:	CA
Zip	:	95603-5808
Country	:	US
Telephone Number	:	530-477-3378
Fax Number	:	530-477-7068

Provider Business Practice Location Address
First Line	:	11270 ROUGH AND READY HWY
Second Line	:
City	:	GRASS VALLEY
State	:	CA
Zip	:	95945-8530
Country	:	US
Telephone Number	:	530-477-3378
Fax Number	:	530-477-7068

Authorized Official
Title or Position	:	OWNER/PRESIDENT/CEO
Name	:	MR. MICHAEL LYMAN
Credential	:	MS
Telephone Number	:	435-881-6338

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	02/21/2022

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