MEDICARE: CCRC OPCO - GALLERIA WOODS, 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1982633632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CCRC OPCO - GALLERIA WOODS, LLC

Provider Business Mailing Address
First Line	:	3850 GALLERIA WOODS DR
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35244-1098
Country	:	US
Telephone Number	:	205-985-7537
Fax Number	:

Provider Business Practice Location Address
First Line	:	3850 GALLERIA WOODS DR
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35244-1098
Country	:	US
Telephone Number	:	205-985-7537
Fax Number	:

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

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	10/03/2014

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