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NPI Code Detail

MEDICARE: CCG PRESCOTT, INC

MEDICARE: CCG PRESCOTT, INC
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
1314000000XSkilled Nursing Facility3249WI

Other Identifiers

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

General Provider Information

NPI Number : 1922090521
Entity Type Code : Organization
Provider Name (Legal Business Name) : CCG PRESCOTT, INC
Provider Business Mailing Address
First Line : 5000 HAKES DR
Second Line : SUITE 600
City : NORTON SHORES
State : MI
Zip : 49441-5574
Country : US
Telephone Number : 231-799-6870
Fax Number : 231-799-0250
Provider Business Practice Location Address
First Line : 1505 ORRIN RD
Second Line :
City : PRESCOTT
State : WI
Zip : 54021-1074
Country : US
Telephone Number : 715-262-5661
Fax Number : 715-262-4899
Authorized Official
Title or Position : CFO
Name : KEITH YODER
Credential :
Telephone Number : 614-416-0600
Provider Enumeration Date : 08/19/2005
Last Update Date : 01/23/2008

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