Country Club Retirement Center LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

3469 Issued in OH

Legal business name

COUNTRY CLUB RETIREMENT CENTER LLC

Practice address

925 E 26TH St
Ashtabula, OH 44004-5061

Phone

(440) 992-0022

Fax

(440) 992-7423

NPI assigned

Jan 18, 2007

Organization subpart

No

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

Authorized official

Name

Mrs. Janet Harris, CPA

Title

Ceo

Phone

(330) 239-4474

Specialties & licenses 2

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in OH

Enrollment records 1

Skilled nursing facility certification: CCN 365642

Legal name

COUNTRY CLUB RETIREMENT CENTER LLC

Certification status

Active

Provider type (POS)

Nursing home – SNF/NF dual certification

Participating since

Dec 13, 1984

Last certification

May 9, 2024

Beds

73

Ownership / control type

Corporation

Organization structure

LLCProprietary

Incorporated

Feb 24, 1984 in OH

Enrollment address

925E 26TH St
Ashtabula, OH 44004-5061

Nursing home name

COUNTRY CLUB RET CENTER I I I

Affiliated entity

COUNTRY CLUB REHABILITATION CAMPUS

Listed as

Country Club Ret Center I I ICCN 365642

Overall star rating

4 of 5

Health inspections

3 of 5

Staffing

2 of 5

Quality measures

5 of 5

Type

Medicare and Medicaid

Ownership

For profit - Corporation

Certified

Dec 13, 1984

Medicare certification status

ActiveFrom the Provider of Services file

Certified beds

7370.7 residents per day on average

Chain

Country Club Rehabilitation Campus7 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

Tax ID family

CCRC III-Ashtabula Nursing Home2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Country Club Retirement Center LLC

  • Assisted Living Facility
  • Ashtabula, OH
  • NPI 1538750666
  NPD tax ID

All disclosed owners & managing parties 15

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

Owners & managing parties with NPI records 1

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

• Abdallah Al-Shahed, MD

  • Internal Medicine Physician
  • Westlake, OH
  • NPI 1639159528

  Adp of the SNF, Operational/Managerial Control

  CMS ownership

Facilities with the same owner 3

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

• Country Club Retirement Center IV, Inc

  • Skilled Nursing Facility
  • Bellaire, OH
  • NPI 1881747673

  Holland Group II, LTD

  CMS ownership
• Country Club Retirement Center V LLC

  • Skilled Nursing Facility
  • Delaware, OH
  • NPI 1881021830

  Holland Group II, LTD

  CMS ownership
• Mount Vernon Elderly Services LLC

  • Skilled Nursing Facility
  • Mount Vernon, OH
  • NPI 1598831869

  Holland Group II, LTD

  CMS ownership

Practitioners 2

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

• Abdallah Al-Shahed, MD

  • Internal Medicine Physician
  • Westlake, OH
  • NPI 1639159528
  NPD (past)
• Almon Seenam Lee, M.D.

  • Internal Medicine Physician
  • Ashtabula, OH
  • NPI 1780677310
  NPD (past)

Affiliated clinicians 1

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

• Almon Seenam Lee, M.D.

  • Internal Medicine Physician
  • Ashtabula, OH
  • NPI 1780677310

  Nursing home

  Care Compare affiliation

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

{
    "created_epoch": "1169078400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1365724800000",
    "number": "1144372137",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 345",
            "city": "SHARON CENTER",
            "state": "OH",
            "postal_code": "442740345",
            "telephone_number": "330-239-4474",
            "fax_number": "330-239-4479"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "925 E 26TH ST",
            "city": "ASHTABULA",
            "state": "OH",
            "postal_code": "440045061",
            "telephone_number": "440-992-0022",
            "fax_number": "440-992-7423"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY CLUB RETIREMENT CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-18",
        "last_updated": "2013-04-12",
        "status": "A",
        "authorized_official_last_name": "HARRIS",
        "authorized_official_first_name": "JANET",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "330-239-4474",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "CPA"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": "OH",
            "license": "4561",
            "primary": false
        },
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "OH",
            "license": "3469",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM",
            "identifier": "000000157279",
            "state": "OH"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0571322",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Erica Corbett, LPCC, LICDC
• Stephanie Marie Corlew
• Brandi Cornell
• Veronica Corwin
• Tammy Cottrell
• Country Club Retirement Center LLC
• Scott S Coursen, RPH
• Henry George Covetta, OD
• Brittany Cox
• James W. Cozy, MA

• Skilled Nursing Facility in Ashtabula, OH
• Providers in Ashtabula, OH by specialty
• Skilled Nursing Facility in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 12, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.