Provider Demographics
NPI:1073099495
Name:CCC OF WEST GREEN BAY
Entity Type:Organization
Organization Name:CCC OF WEST GREEN BAY
Other - Org Name:CROSSROADS CARE CENTER OF WEST GREEN BAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MERZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-983-4860
Mailing Address - Street 1:8150 CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2974
Mailing Address - Country:US
Mailing Address - Phone:847-983-4860
Mailing Address - Fax:
Practice Address - Street 1:1760 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3216
Practice Address - Country:US
Practice Address - Phone:847-983-4860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000000000Medicaid