Healthcare Provider Details

I. General information

NPI: 1821178427
Provider Name (Legal Business Name): COUNTRY CLUB CENTER HOMES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 E IRON AVE
DOVER OH
44622-2031
US

IV. Provider business mailing address

860 E IRON AVE
DOVER OH
44622-2031
US

V. Phone/Fax

Practice location:
  • Phone: 330-343-5568
  • Fax: 330-343-0514
Mailing address:
  • Phone: 330-343-5568
  • Fax: 330-343-0514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2499
License Number StateOH

VIII. Authorized Official

Name: MR. MICHAEL M HOHMAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 330-343-5568