Healthcare Provider Details

I. General information

NPI: 1881021830
Provider Name (Legal Business Name): COUNTRY CLUB RETIREMENT CENTER V LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2013
Last Update Date: 10/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

478 S SANDUSKY ST
DELAWARE OH
43015-2623
US

IV. Provider business mailing address

PO BOX 427
SHARON CENTER OH
44274-0427
US

V. Phone/Fax

Practice location:
  • Phone: 740-369-8741
  • Fax: 740-363-8359
Mailing address:
  • Phone: 330-239-4474
  • Fax: 330-239-4479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1413N
License Number StateOH

VIII. Authorized Official

Name: HAYLEY B WILLIAMS
Title or Position: ATTORNEY
Credential:
Phone: 216-706-3936