Provider Demographics
NPI:1174072482
Name:CROSSROADS 1010 LLC
Entity type:Organization
Organization Name:CROSSROADS 1010 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-317-7002
Mailing Address - Street 1:P.O. BO 1012
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523
Mailing Address - Country:US
Mailing Address - Phone:580-271-7080
Mailing Address - Fax:580-298-2081
Practice Address - Street 1:193908 US HWY 271
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523
Practice Address - Country:US
Practice Address - Phone:580-271-7080
Practice Address - Fax:580-298-2081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200734990AMedicaid