Provider Demographics
NPI:1700281219
Name:CCR OTC LLC
Entity Type:Organization
Organization Name:CCR OTC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BACHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-671-0161
Mailing Address - Street 1:819 W GURLEY ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-3626
Mailing Address - Country:US
Mailing Address - Phone:928-671-0161
Mailing Address - Fax:928-708-9620
Practice Address - Street 1:819 W GURLEY ST UNIT C
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-3626
Practice Address - Country:US
Practice Address - Phone:928-671-0161
Practice Address - Fax:928-708-9620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10486261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder