Provider Demographics
NPI:1881021830
Name:COUNTRY CLUB RETIREMENT CENTER V LLC
Entity Type:Organization
Organization Name:COUNTRY CLUB RETIREMENT CENTER V LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:
Authorized Official - First Name:HAYLEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-706-3936
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:SHARON CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:44274-0427
Mailing Address - Country:US
Mailing Address - Phone:330-239-4474
Mailing Address - Fax:330-239-4479
Practice Address - Street 1:478 S SANDUSKY ST
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-2623
Practice Address - Country:US
Practice Address - Phone:740-369-8741
Practice Address - Fax:740-363-8359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-07
Last Update Date:2013-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1413N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH366026Medicare Oscar/Certification