1609260371 NPI number — CCRC OPCO - FREEDOM SQUARE, LLC

Table of content: (NPI 1609260371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609260371 NPI number — CCRC OPCO - FREEDOM SQUARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCRC OPCO - FREEDOM SQUARE, 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:
Provider Other Organization Name Type Code:
6
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:
1609260371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10801 JOHNSON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEMINOLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33772-4746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-398-0379
Provider Business Mailing Address Fax Number:
727-398-0461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6737 W WASHINGTON ST
Provider Second Line Business Practice Location Address:
SUITE 2300
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53214-5647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-918-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2015

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: 310400000X , with the licence number:  AL4759 , 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: 104046100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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