Basic Information
| Provider Information | |||||||||
| NPI: | 1104875152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CCRC OPCO - FREEDOM SQUARE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SEMINOLE PAVILION REHABILITATION & NURSING SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10800 TEMPLE TERRACE | ||||||||
| Address2: | |||||||||
| City: | SEMINOLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337724736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273980166 | ||||||||
| FaxNumber: | 7273980188 | ||||||||
| Practice Location | |||||||||
| Address1: | 10800 TEMPLE TERRACE | ||||||||
| Address2: | |||||||||
| City: | SEMINOLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337724736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273980166 | ||||||||
| FaxNumber: | 7273980188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| 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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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF14960961 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 032423000 | 05 | FL | MEDICAID |