Healthcare Provider Details

I. General information

NPI: 1437636636
Provider Name (Legal Business Name): CCRM DFW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8380 WARREN PKWY STE 201
FRISCO TX
75034
US

IV. Provider business mailing address

8380 WARREN PKWY STE 201
FRISCO TX
75034-4199
US

V. Phone/Fax

Practice location:
  • Phone: 972-377-2625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MATT TYSON
Title or Position: DIRECTOR, MANAGED CARE CONTRACTING
Credential:
Phone: 615-477-6677