Basic Information
| Provider Information | |||||||||
| NPI: | 1013947084 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CCRC OPCO - BRADENTON, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | THE NURSING CENTER AT FREEDOM VILLAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 WESTWOOD PL | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152212250 | ||||||||
| FaxNumber: | 6152212269 | ||||||||
| Practice Location | |||||||||
| Address1: | 6410 21ST AVE W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342097854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417988200 | ||||||||
| FaxNumber: | 9417988305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 10/03/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OHLENDORF | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4149185000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BROOKDALE SENIOR LIVING INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF1168096 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.