Healthcare Provider Details

I. General information

NPI: 1073908810
Provider Name (Legal Business Name): CCR INTERGRATED HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12268 W DELWOOD DRIVE 3699
ARIZONA CITY AZ
85123
US

IV. Provider business mailing address

P.O. BOX 3699
ARIZONA CITY AZ
85123
US

V. Phone/Fax

Practice location:
  • Phone: 228-383-1240
  • Fax:
Mailing address:
  • Phone: 228-383-1240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateAZ

VIII. Authorized Official

Name: MR. CLARENCE VANARD BURTON
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 228-383-1240