1295870699 NPI number — CCRI, INC

Table of content: (NPI 1295870699)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295870699 NPI number — CCRI, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCRI, INC
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:
CREATIVE CARE FOR REACHING INDEPENDENCE
Provider Other Organization Name Type Code:
3
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:
1295870699
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2903 15TH ST S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORHEAD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56560-5111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-236-6730
Provider Business Mailing Address Fax Number:
218-236-1481

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2903 15TH ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-5111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-236-6730
Provider Business Practice Location Address Fax Number:
218-236-1481
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOCK
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
218-236-6730

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320900000X , with the licence number: 800502 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001418000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 304720200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 702420000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 403445700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 409343700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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