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General NPI Number Information
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NPI Number | 1295870699
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Entity Type | Organization
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Legal Business Name | CCRI, INC
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Dates
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Enumeration Date | 02/21/2007
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Last Update Date | 08/13/2014
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Provider Practice Location Address
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Address Line | 2903 15TH ST S
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City | MOORHEAD
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State | MN
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Zip | 56560-5111
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Country | US
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Telephone | 218-236-6730
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Fax | 218-236-1481
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Provider Business Mailing Address
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Address Line | 2903 15TH ST S
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City | MOORHEAD
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State | MN
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Zip | 56560-5111
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Country | US
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Telephone | 218-236-6730
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Fax | 218-236-1481
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. SHANNON BOCK
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Credential |
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Telephone | 218-236-6730
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State | MN
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Taxonomy #4
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 800502
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License Number State | MN
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