1013947084 NPI number — CCRC OPCO - BRADENTON, LLC

Table of content: (NPI 1013947084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013947084 NPI number — CCRC OPCO - BRADENTON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCRC OPCO - BRADENTON, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE NURSING CENTER AT FREEDOM VILLAGE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013947084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 WESTWOOD PL
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-5021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-221-2250
Provider Business Mailing Address Fax Number:
615-221-2269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6410 21ST AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34209-7854
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-798-8200
Provider Business Practice Location Address Fax Number:
941-798-8305
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OHLENDORF
Authorized Official First Name:
MARK
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
414-918-5000

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF1168096 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 018360900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com