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General NPI Number Information
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NPI Number | 1376659060
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Entity Type | Organization
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Legal Business Name | MOUNTAIN CRC INC
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Dates
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Enumeration Date | 08/22/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1240 DANCING HORSE DR
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City | COLORADO SPRINGS
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State | CO
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Zip | 80919-3910
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Country | US
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Telephone | 719-676-7060
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Fax | 719-676-7808
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Provider Business Mailing Address
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Address Line | 5691 HOUSMAN AVE
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City | PUEBLO
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State | CO
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Zip | 81004-9709
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Country | US
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Telephone | 719-676-7060
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Fax | 719-676-7808
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | BRIDGET S PETERSON
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Credential |
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Telephone | 719-676-7060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 123859
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License Number State | CO
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