Organization
COUNTRY CLUB RETIREMENT CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JANET HARRIS CPA (CEO)
(330) 239-4474
Entity
Organization
Contact information
Practice address
925 E 26TH ST, ASHTABULA, OH 44004-5061
(440) 992-0022
(440) 992-7423
Mailing address
PO BOX 345, SHARON CENTER, OH 44274-0345
(330) 239-4474
(330) 239-4479
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
4561
OH
314000000X
Skilled Nursing Facility
Primary
3469
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000157279
ANTHEM
OH
05
—
0571322
—
OH
Enumeration date
01/18/2007
Last updated
04/12/2013
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