MEDICARE: CROSSROADS HOSPICE OF DAYTON LLC

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	207QH0002X	Hospice and Palliative Medicine (Family Medicine) Physician
2	251G00000X	Community Based Hospice Care Agency	0168HSP	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679741128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSROADS HOSPICE OF DAYTON LLC

Provider Business Mailing Address
First Line	:	10810 E 45TH ST STE 300
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74146-3816
Country	:	US
Telephone Number	:	918-627-6846
Fax Number	:	918-627-6856

Provider Business Practice Location Address
First Line	:	8069 WASHINGTON VILLAGE DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45458-1847
Country	:	US
Telephone Number	:	937-312-3170
Fax Number	:	937-439-5903

Authorized Official
Title or Position	:	CFO/COO
Name	:	MR. CLAYTON FARMER
Credential	:
Telephone Number	:	918-627-6846

Provider Enumeration Date	:	02/19/2008
Last Update Date	:	11/14/2022

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