Provider Demographics
NPI:1033168992
Name:CCRC OPCO - FREEDOM SQUARE, LLC
Entity Type:Organization
Organization Name:CCRC OPCO - FREEDOM SQUARE, LLC
Other - Org Name:FREEDOM SQUARE REHABILITATION & NURSING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MIKI
Authorized Official - Middle Name:C
Authorized Official - Last Name:STATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-398-0166
Mailing Address - Street 1:10801 JOHNSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-4746
Mailing Address - Country:US
Mailing Address - Phone:727-398-0166
Mailing Address - Fax:
Practice Address - Street 1:10801 JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-4746
Practice Address - Country:US
Practice Address - Phone:727-398-0166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKDALE SENIOR LIVING INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-09
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1167096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032424800Medicaid
FL106042Medicare Oscar/Certification