Provider Demographics
NPI:1760814644
Name:CCCRIC LLC
Entity Type:Organization
Organization Name:CCCRIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALVORSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-788-8675
Mailing Address - Street 1:799 E HAMPDEN AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-2777
Mailing Address - Country:US
Mailing Address - Phone:303-788-8675
Mailing Address - Fax:303-788-8489
Practice Address - Street 1:799 E HAMPDEN AVE STE 500
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2777
Practice Address - Country:US
Practice Address - Phone:303-788-8675
Practice Address - Fax:303-788-8489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-02
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68524374Medicaid
CO68524374Medicaid