NPIMap

Organization Active NPI

Country Lane Manor LLC

  • Skilled Nursing Facility
  • Keosauqua, IA
National Provider Identifier
1073347902
Registry record updated Sep 2, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
COUNTRY LANE MANOR LLC
Practice address
819 Country Lane Rd
Keosauqua, IA 52565-1001
Phone
(319) 293-3761
NPI assigned
Sep 2, 2024
Last updated
Sep 2, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 2, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Joseph Glatzer
Title
Authorized Representative
Phone
(848) 757-0550

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

Addresses

Primary practice location

819 Country Lane Rd
Keosauqua, IA 52565-1001

Mailing address

819 Country Lane Rd
Keosauqua, IA 52565-1001

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20250228003125 IA Part A Provider - Skilled Nursing Facility 0941721344 Practice locations: Keosauqua, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1073347902. Details of each certification follow.

Skilled nursing facility certification: CCN 165204

Legal name
COUNTRY LANE MANOR LLC
Doing business as
COUNTRY LANE MANOR
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
May 1, 1994
Last certification
Sep 16, 2024
Beds
60
Ownership / control type
Limited Liability Corporation
Organization structure
LLCProprietary
Enrollment address
819 Country Lane Rd
Keosauqua, IA 52565-1001
Nursing home name
COUNTRY LANE MANOR
Affiliated entity
CEDAR VIEW HOLDINGS

Care Compare: Nursing home

Medicare Care Compare
Listed as
Country Lane ManorCCN 165204 · All quality measures
Overall star rating
1 of 5
Health inspections
1 of 5
Staffing
1 of 5
Quality measures
4 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
May 1, 1994
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
6050.9 residents per day on average
Chain
Cedar View Holdings9 facilities in the chain
Penalties (3 years)
2Fines totaling $59,150

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 18

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Gabriel J Sebbag Individual 5% Or Greater Indirect Ownership InterestPresident Jan 1, 2025 52%
David T Gamzeh Individual Trustee of the SNF Jan 1, 2025
Samara Fam TR Organization, Lawrence, NY For-profit 5% Or Greater Indirect Ownership Interest Jan 1, 2025 24%
Adp of the SNF Jan 1, 2025
JSJ 2020 Fam TR Organization, Greenville, DE For-profit Adp of the SNF Jan 1, 2025
Dana R Brecount Individual Operational/Managerial Control Jan 1, 2025
Adp of the SNF Jan 1, 2025
Iowa 5784 LLC Organization, Passaic, NJ LLC, For-profit, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Jan 1, 2025 52%
819 Country Lane Road Propco LLC Organization, Hewlett, NY LLC, For-profit Adp of the SNF Jan 1, 2025
Amaranthine Holdings LLC Organization, Valley Stream, NY LLC, For-profit, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jan 1, 2025 100%
JSJ Property LLC Organization, Lawrence, NY LLC, For-profit Adp of the SNF Jan 1, 2025
Cedar View TR Organization, Greenville, DE For-profit 5% Or Greater Indirect Ownership Interest Jan 1, 2025 24%
Caresage Administrative Consulting, LLC Organization, Valley Stream, NY LLC, Consulting firm, For-profit Adp of the SNF Jan 1, 2025
The Bryn Mawr Trust Company of Delaware Organization, Wilmington, DE For-profit Adp of the SNF Jan 1, 2025
Summation Financial Services LLC Organization, Howell, NJ LLC, For-profit Adp of the SNF Jan 1, 2025
JSJ Family Trust Organization, Greenville, DE For-profit Adp of the SNF Jan 1, 2025
Calla Mallett Individual Operational/Managerial Control Jan 1, 2025
Adp of the SNF Jan 1, 2025
Clinical Consulting Services LLC Organization, Eddystone, PA LLC, Consulting firm, For-profit Adp of the SNF Jan 1, 2025
Samara Family Holdings LLC Organization, New York, NY LLC, For-profit, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Jan 1, 2025 24%
Adp of the SNF Jan 1, 2025
Cedar View Holdings LLC Organization, Greenville, DE LLC, For-profit, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Jan 1, 2025 24%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 9

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1725235200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1725235200000",
    "number": "1073347902",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "819 COUNTRY LANE RD",
            "city": "KEOSAUQUA",
            "state": "IA",
            "postal_code": "525651001"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "819 COUNTRY LANE RD",
            "city": "KEOSAUQUA",
            "state": "IA",
            "postal_code": "525651001",
            "telephone_number": "319-293-3761"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY LANE MANOR LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-09-02",
        "last_updated": "2024-09-02",
        "certification_date": "2024-09-02",
        "status": "A",
        "authorized_official_last_name": "GLATZER",
        "authorized_official_first_name": "JOSEPH",
        "authorized_official_title_or_position": "AUTHORIZED REPRESENTATIVE",
        "authorized_official_telephone_number": "848-757-0550"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Keosauqua, IA

Sources for this page

Verify at the official NPI Registry.