Healthcare Provider Details

I. General information

NPI: 1366440430
Provider Name (Legal Business Name): CCG - FREDERIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 UNITED WAY
FREDERIC WI
54837-8938
US

IV. Provider business mailing address

5000 HAKES DR SUITE 600
NORTON SHORES MI
49441-5574
US

V. Phone/Fax

Practice location:
  • Phone: 715-327-4297
  • Fax: 715-327-4950
Mailing address:
  • Phone: 231-799-6870
  • Fax: 231-799-0250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3086
License Number StateWI

VIII. Authorized Official

Name: KEITH YODER
Title or Position: CFO
Credential:
Phone: 614-416-0600