MEDICARE: CCRC OPCO - FREEDOM SQUARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	AL4759	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609260371
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CCRC OPCO - FREEDOM SQUARE, LLC

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

Provider Business Practice Location Address
First Line	:	6737 W WASHINGTON ST
Second Line	:	SUITE 2300
City	:	MILWAUKEE
State	:	WI
Zip	:	53214-5647
Country	:	US
Telephone Number	:	414-918-5000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MARK W OHLENDORF
Credential	:
Telephone Number	:	414-918-5000

Provider Enumeration Date	:	03/20/2015
Last Update Date	:	03/20/2015

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