Provider Demographics
NPI:1104875152
Name:CCRC OPCO - FREEDOM SQUARE, LLC
Entity type:Organization
Organization Name:CCRC OPCO - FREEDOM SQUARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:OHLENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-918-5000
Mailing Address - Street 1:10800 TEMPLE TERRACE
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-4736
Mailing Address - Country:US
Mailing Address - Phone:727-398-0166
Mailing Address - Fax:727-398-0188
Practice Address - Street 1:10800 TEMPLE TERRACE
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-4736
Practice Address - Country:US
Practice Address - Phone:727-398-0166
Practice Address - Fax:727-398-0188
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKDALE SENIOR LIVING INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-08
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF14960961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032423000Medicaid
FL032423000Medicaid