Provider Demographics
NPI:1881747673
Name:COUNTRY CLUB RETIREMENT CENTER IV, INC
Entity type:Organization
Organization Name:COUNTRY CLUB RETIREMENT CENTER IV, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:330-239-4474
Mailing Address - Street 1:PO BOX 345
Mailing Address - Street 2:
Mailing Address - City:SHARON CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:44274-0345
Mailing Address - Country:US
Mailing Address - Phone:330-239-4474
Mailing Address - Fax:330-239-4479
Practice Address - Street 1:55801 CONNO MARA DR
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:OH
Practice Address - Zip Code:43906-9698
Practice Address - Country:US
Practice Address - Phone:800-516-9389
Practice Address - Fax:740-676-1277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1858R310400000X
OH3761314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0640051Medicaid
OH000000335475OtherANTHEM
OH365699Medicare ID - Type Unspecified