1073908810 NPI number — CCR INTERGRATED HEALTH

Table of content: (NPI 1073908810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073908810 NPI number — CCR INTERGRATED HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCR INTERGRATED HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
N/A
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073908810
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 3699
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARIZONA CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-383-1240
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12268 W DELWOOD DRIVE
Provider Second Line Business Practice Location Address:
3699
Provider Business Practice Location Address City Name:
ARIZONA CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-383-1240
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BURTON
Authorized Official First Name:
CLARENCE
Authorized Official Middle Name:
VANARD
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
228-383-1240

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 323P00000X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 503218 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com