CCG - Frederic

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

3086 Issued in WI

Legal business name

CCG - FREDERIC

Practice address

205 United Way
Frederic, WI 54837-8938

Phone

(715) 327-4297

Fax

(715) 327-4950

NPI assigned

Jul 12, 2005

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Keith Yoder

Title

Cfo

Phone

(614) 416-0600

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Frederic Nursing and Rehabilitation Community Doing business as

Tax ID family

CCG - Frederic2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Orion Frederic LLC

  • Skilled Nursing Facility
  • Frederic, WI
  • NPI 1528246626
  NPD tax ID

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1121126400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1208649600000",
    "number": "1366440430",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5000 HAKES DR",
            "address_2": "SUITE 600",
            "city": "NORTON SHORES",
            "state": "MI",
            "postal_code": "494415574",
            "telephone_number": "231-799-6870",
            "fax_number": "231-799-0250"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "205 UNITED WAY",
            "city": "FREDERIC",
            "state": "WI",
            "postal_code": "548378938",
            "telephone_number": "715-327-4297",
            "fax_number": "715-327-4950"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CCG - FREDERIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-12",
        "last_updated": "2008-04-20",
        "status": "A",
        "authorized_official_last_name": "YODER",
        "authorized_official_first_name": "KEITH",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "614-416-0600"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "WI",
            "license": "3086",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "20191100",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Frederic Nursing and Rehabilitation Community",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Elizabeth Kay Anderson, RN
• Laurie A Breeden
• Annalise Parks Brenizer, PHARMD
• Kyle Clemins, LPC-IT
• Casey Denver, R.N.
• Elizabeth Drews
• Debra Irene Erwin
• Ashley A Esanbock, LPC-IT

• All providers in Frederic, WI
• Skilled Nursing Facility in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 20, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.