Provider Demographics
NPI:1679741128
Name:CROSSROADS HOSPICE OF DAYTON LLC
Entity type:Organization
Organization Name:CROSSROADS HOSPICE OF DAYTON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-627-6846
Mailing Address - Street 1:10810 E 45TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-3816
Mailing Address - Country:US
Mailing Address - Phone:918-627-6846
Mailing Address - Fax:918-627-6856
Practice Address - Street 1:8069 WASHINGTON VILLAGE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45458-1847
Practice Address - Country:US
Practice Address - Phone:937-312-3170
Practice Address - Fax:937-439-5903
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARREFOUR ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-19
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QH0002X
OH0168HSP251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251G00000XAgenciesHospice Care, Community Based
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3133120Medicaid
OH3133120Medicaid