Provider Demographics
NPI:1588102438
Name:CROSSROADS TREATMENT CENTER OF LAGRANGE, PC
Entity type:Organization
Organization Name:CROSSROADS TREATMENT CENTER OF LAGRANGE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUPERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MCCORMAC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-805-6989
Mailing Address - Street 1:PO BOX 749057
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9057
Mailing Address - Country:US
Mailing Address - Phone:800-805-6989
Mailing Address - Fax:864-558-8511
Practice Address - Street 1:229 S DAVIS RD
Practice Address - Street 2:SUITE 900
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-2608
Practice Address - Country:US
Practice Address - Phone:008-056-9898
Practice Address - Fax:864-558-8511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-10
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GANTP001092OtherSTATE LICENSE