Provider Demographics
NPI:1568412690
Name:CCRC OPCO - HOLLAND, LLC
Entity Type:Organization
Organization Name:CCRC OPCO - HOLLAND, LLC
Other - Org Name:THE INN AT FREEDOM VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-2250
Mailing Address - Street 1:145 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-2981
Mailing Address - Country:US
Mailing Address - Phone:616-820-7400
Mailing Address - Fax:616-820-7410
Practice Address - Street 1:145 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-2981
Practice Address - Country:US
Practice Address - Phone:616-820-7400
Practice Address - Fax:616-820-7410
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:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI704011314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235548Medicare Oscar/Certification