Provider Demographics
NPI:1609260371
Name:CCRC OPCO - FREEDOM SQUARE, LLC
Entity Type:Organization
Organization Name:CCRC OPCO - FREEDOM SQUARE, LLC
Other - Org Name:THE INN AT FREEDOM SQUARE
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 1:10801 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:727-398-0379
Mailing Address - Fax:727-398-0461
Practice Address - Street 1:6737 W WASHINGTON ST
Practice Address - Street 2:SUITE 2300
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-5647
Practice Address - Country:US
Practice Address - Phone:414-918-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKDALE SENIOR LIVING, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL4759310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility