Provider Demographics
NPI:1821178427
Name:COUNTRY CLUB CENTER HOMES, INC
Entity Type:Organization
Organization Name:COUNTRY CLUB CENTER HOMES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-343-5568
Mailing Address - Street 1:860 E IRON AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2031
Mailing Address - Country:US
Mailing Address - Phone:330-343-5568
Mailing Address - Fax:330-343-0514
Practice Address - Street 1:860 E IRON AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2031
Practice Address - Country:US
Practice Address - Phone:330-343-5568
Practice Address - Fax:330-343-0514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2499314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0400828Medicaid
OH0400828Medicaid