Provider Demographics
NPI:1558311654
Name:CCRC OPCO - SUN CITY CENTER, LLC
Entity Type:Organization
Organization Name:CCRC OPCO - SUN CITY CENTER, LLC
Other - Org Name:PLAZA WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:OHLENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-918-5000
Mailing Address - Street 1:1010 AMERICAN EAGLE BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY CENTER
Mailing Address - State:FL
Mailing Address - Zip Code:33573-5284
Mailing Address - Country:US
Mailing Address - Phone:813-633-1992
Mailing Address - Fax:
Practice Address - Street 1:1010 AMERICAN EAGLE BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-5284
Practice Address - Country:US
Practice Address - Phone:813-633-1992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKDALE SENIOR LIVING INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-11
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1618096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021188500Medicaid
FL105866Medicare Oscar/Certification