Provider Demographics
NPI:1366440430
Name:CCG - FREDERIC
Entity Type:Organization
Organization Name:CCG - FREDERIC
Other - Org Name:FREDERIC NURSING AND REHABILITATION COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:YODER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-416-0600
Mailing Address - Street 1:5000 HAKES DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-5574
Mailing Address - Country:US
Mailing Address - Phone:231-799-6870
Mailing Address - Fax:231-799-0250
Practice Address - Street 1:205 UNITED WAY
Practice Address - Street 2:
Practice Address - City:FREDERIC
Practice Address - State:WI
Practice Address - Zip Code:54837-8938
Practice Address - Country:US
Practice Address - Phone:715-327-4297
Practice Address - Fax:715-327-4950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3086314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20191100Medicaid
WI=========019OtherBCBS PROVIDER CODE
WI20191100Medicaid