Provider Demographics
NPI:1013947084
Name:CCRC OPCO - BRADENTON, LLC
Entity type:Organization
Organization Name:CCRC OPCO - BRADENTON, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:111 WESTWOOD PL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5021
Mailing Address - Country:US
Mailing Address - Phone:615-221-2250
Mailing Address - Fax:615-221-2269
Practice Address - Street 1:6410 21ST AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-7854
Practice Address - Country:US
Practice Address - Phone:941-798-8200
Practice Address - Fax:941-798-8305
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKDALE SENIOR LIVING INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-04
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1168096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105655Medicare Oscar/Certification