Provider Demographics
NPI:1295870699
Name:CCRI, INC
Entity type:Organization
Organization Name:CCRI, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-236-6730
Mailing Address - Street 1:2903 15TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5111
Mailing Address - Country:US
Mailing Address - Phone:218-236-6730
Mailing Address - Fax:218-236-1481
Practice Address - Street 1:2903 15TH ST S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5111
Practice Address - Country:US
Practice Address - Phone:218-236-6730
Practice Address - Fax:218-236-1481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251E00000X, 251S00000X, 261QM0801X
MN800502320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN001418000Medicaid
MN304720200Medicaid
MN702420000Medicaid
MN403445700Medicaid
MN409343700Medicaid
MN403445700Medicaid