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General NPI Number Information
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NPI Number | 1609260371
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Entity Type | Organization
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Legal Business Name | CCRC OPCO - FREEDOM SQUARE, LLC
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Dates
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Enumeration Date | 03/20/2015
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Last Update Date | 03/20/2015
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Provider Practice Location Address
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Address Line | 6737 W WASHINGTON ST SUITE 2300
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City | MILWAUKEE
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State | WI
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Zip | 53214-5647
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Country | US
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Telephone | 414-918-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 10801 JOHNSON BLVD
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City | SEMINOLE
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State | FL
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Zip | 33772-4746
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Country | US
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Telephone | 727-398-0379
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Fax | 727-398-0461
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. MARK W OHLENDORF
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Credential |
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Telephone | 414-918-5000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL4759
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License Number State | FL
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