Provider Demographics
NPI:1437636636
Name:CCRM DFW, LLC
Entity Type:Organization
Organization Name:CCRM DFW, LLC
Other - Org Name:CCRM DALLAS FORT WORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:PARDEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-968-1950
Mailing Address - Street 1:9380 STATION ST STE 425
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-6832
Mailing Address - Country:US
Mailing Address - Phone:303-968-1950
Mailing Address - Fax:
Practice Address - Street 1:8380 WARREN PKWY STE 201
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034
Practice Address - Country:US
Practice Address - Phone:972-377-2625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-20
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
45D1095599OtherCLIA
130394OtherASC LICENSE