Provider Demographics
NPI:1376659060
Name:MOUNTAIN CRC INC
Entity Type:Organization
Organization Name:MOUNTAIN CRC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-676-7060
Mailing Address - Street 1:5691 HOUSMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-9709
Mailing Address - Country:US
Mailing Address - Phone:719-676-7060
Mailing Address - Fax:719-676-7808
Practice Address - Street 1:1240 DANCING HORSE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3910
Practice Address - Country:US
Practice Address - Phone:719-676-7060
Practice Address - Fax:719-676-7808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO123859163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty