Basic Information
Provider Information | |||||||||
NPI: | 1356453609 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CCRC OPCO - FOXWOOD SPRINGS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FOXWOOD SPRINGS LIVING CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 W FOXWOOD DR | ||||||||
Address2: |   | ||||||||
City: | RAYMORE | ||||||||
State: | MO | ||||||||
PostalCode: | 640839347 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8163313111 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1500 W FOXWOOD DR | ||||||||
Address2: |   | ||||||||
City: | RAYMORE | ||||||||
State: | MO | ||||||||
PostalCode: | 640839372 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8163313111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 11/11/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OHLENDORF | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | CFO & PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4149185000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BROOKDALE SENIOR LIVING INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 032980 | MO | N |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   | 314000000X | 032979 | MO | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 101486306 | 05 | MO |   | MEDICAID |