NPIMap

Organization Active NPI

Country Club Operator LLC

  • Skilled Nursing Facility
  • Warrensburg, MO
National Provider Identifier
1104584416
Registry record updated Dec 3, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
COUNTRY CLUB OPERATOR LLC
Practice address
503 Regent Dr
Warrensburg, MO 64093-3231
Phone
(660) 429-4444
NPI assigned
Dec 3, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 3, 2021

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

Authorized official

Name
Mr. Jacques Wolf
Title
Manager
Phone
(908) 421-1184

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

Addresses

Primary practice location

503 Regent Dr
Warrensburg, MO 64093-3231

Mailing address

311 Boulevard of the Americas
Suite 201
Lakewood, NJ 08701
Phone (908) 621-1184

Other names 1

  • Country Club Rehab and Healthcare Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211221001910 MO Part A Provider - Skilled Nursing Facility 1759772064 Practice locations: Warrensburg, MO

Skilled nursing facility certification: CCN 265645

Legal name
COUNTRY CLUB OPERATOR LLC
Doing business as
COUNTRY CLUB REHAB AND HEALTHCARE CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
May 9, 1996
Last certification
Mar 14, 2025
Beds
73
Ownership / control type
Limited Liability Corporation
Multi-facility organization
LUXOR
Most recent change of ownership
Jan 1, 2022
Organization structure
LLCProprietary
Incorporated
Sep 2, 2021 in MO
Enrollment address
503 Regent Dr
Warrensburg, MO 64093-3231
Nursing home name
COUNTRY CLUB REHAB AND HEALTHCARE CENTER
Affiliated entity
AMA HOLDINGS

Care Compare: Nursing home

Medicare Care Compare
Listed as
Country Club Rehab and Healthcare CenterCCN 265645
Overall star rating
1 of 5
Health inspections
2 of 5
Staffing
1 of 5
Quality measures
3 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
May 9, 1996
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
7358.7 residents per day on average
Chain
Ama Holdings13 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 6

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

NameRoleSinceShare
Asher Marx Individual 5% Or Greater Indirect Ownership Interest Jan 1, 2022 50%
Corporate DirectorManaging Member Jan 1, 2022 50%
Operational/Managerial ControlManaging Member Jan 1, 2022 50%
Def Holdings LLC Organization, Lakewood, NJ LLC, For-profit 5% Or Greater Indirect Ownership Interest Jan 1, 2022 50%
Mo Operation Holdings de Spe LLC Organization, Lakewood, NJ LLC 5% Or Greater Direct Ownership Interest Jan 25, 2024 99%
Operational/Managerial Control Jan 25, 2024 99%
Krystal Landon Individual W-2 Managing EmployeeAd; Jan 30, 2024
Jacques Wolf Individual 5% Or Greater Indirect Ownership Interest Jan 1, 2022 50%
Corporate DirectorManaging Member Jan 1, 2022 50%
Operational/Managerial ControlManaging Member Jan 1, 2022 50%
Ama Holdings LLC Organization, Toms River, NJ LLC 5% Or Greater Indirect Ownership Interest Jan 1, 2022 50%

Facilities with the same owner 12

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

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Affiliated clinicians 2

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": "1638489600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1638489600000",
    "number": "1104584416",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "311 BOULEVARD OF THE AMERICAS",
            "address_2": "SUITE 201",
            "city": "LAKEWOOD",
            "state": "NJ",
            "postal_code": "08701",
            "telephone_number": "908-621-1184"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "503 REGENT DR",
            "city": "WARRENSBURG",
            "state": "MO",
            "postal_code": "640933231",
            "telephone_number": "660-429-4444"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY CLUB OPERATOR LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-12-03",
        "last_updated": "2021-12-03",
        "certification_date": "2021-11-21",
        "status": "A",
        "authorized_official_last_name": "WOLF",
        "authorized_official_first_name": "JACQUES",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "908-421-1184",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Country Club Rehab and Healthcare Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Warrensburg, MO

Sources for this page

Verify at the official NPI Registry.