Provider Demographics
NPI:1104712967
Name:CCRM DONOR EGG BANK LLC
Entity type:Organization
Organization Name:CCRM DONOR EGG BANK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGED CARE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:RAVECH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-305-6640
Mailing Address - Street 1:10290 RIDGEGATE CIR
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5331
Mailing Address - Country:US
Mailing Address - Phone:303-788-8300
Mailing Address - Fax:303-788-8310
Practice Address - Street 1:10290 RIDGEGATE CIR
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5331
Practice Address - Country:US
Practice Address - Phone:303-788-8300
Practice Address - Fax:303-788-8310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0006XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Fertility Facility