Provider Demographics
NPI:1073908810
Name:CCR INTERGRATED HEALTH
Entity Type:Organization
Organization Name:CCR INTERGRATED HEALTH
Other - Org Name:N/A
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:VANARD
Authorized Official - Last Name:BURTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-383-1240
Mailing Address - Street 1:P.O. BOX 3699
Mailing Address - Street 2:
Mailing Address - City:ARIZONA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85123
Mailing Address - Country:US
Mailing Address - Phone:228-383-1240
Mailing Address - Fax:
Practice Address - Street 1:12268 W DELWOOD DRIVE
Practice Address - Street 2:3699
Practice Address - City:ARIZONA CITY
Practice Address - State:AZ
Practice Address - Zip Code:85123
Practice Address - Country:US
Practice Address - Phone:228-383-1240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ320800000X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ503218Medicaid