Healthcare Provider Details

I. General information

NPI: 1104584416
Provider Name (Legal Business Name): COUNTRY CLUB OPERATOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2021
Last Update Date: 12/03/2021
Certification Date: 11/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 REGENT DR
WARRENSBURG MO
64093-3231
US

IV. Provider business mailing address

311 BOULEVARD OF THE AMERICAS SUITE 201
LAKEWOOD NJ
08701
US

V. Phone/Fax

Practice location:
  • Phone: 660-429-4444
  • Fax:
Mailing address:
  • Phone: 908-621-1184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JACQUES WOLF
Title or Position: MANAGER
Credential:
Phone: 908-421-1184