Provider Demographics
NPI:1760431399
Name:CCRC OPCO - CYPRESS VILLAGE, LLC
Entity Type:Organization
Organization Name:CCRC OPCO - CYPRESS VILLAGE, LLC
Other - Org Name:CYPRESS VILLAGE
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 1:330 N WABASH AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3586
Mailing Address - Country:US
Mailing Address - Phone:312-977-3700
Mailing Address - Fax:
Practice Address - Street 1:4600 MIDDLETON PARK CIR E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-5691
Practice Address - Country:US
Practice Address - Phone:901-223-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKDALE SENIOR LIVING INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-10
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL7720310400000X
FLSNF11170961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30799800Medicaid
FL105745Medicare Oscar/Certification