St. Coletta's of Illinois, Inc.

Primary specialty

Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X

Legal business name

ST. COLETTA'S OF ILLINOIS, INC.

Doing business as

Country Club Terrace

Practice address

4900 183Rd St
Country Club Hills, IL 60478-4568

Phone

(708) 647-0752

Fax

(708) 342-2579

NPI assigned

Jan 31, 2008

Organization subpart

No

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

Authorized official

Name

Mrs. Annette Skafgaard, CPA

Title

Director of Finance

Phone

(708) 342-5253

Specialties & licenses 2

Addresses

Other names 1

• Country Club Terrace Doing business as

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Intermediate care facility for individuals with intellectual disabilities certification: CCN 14G271

Legal name

COUNTRY CLUB TERRACE

Certification status

Active

Provider type (POS)

Intermediate care facility for individuals with intellectual disabilities

Participating since

Jun 4, 1991

Last certification

Nov 15, 2024

Beds

16

Ownership / control type

Private (non-profit)

Most recent change of ownership

Jun 19, 2014

Facility address

4900 West 183Rd Street
Country Club Hills, IL 60478

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

St Coletta's of Illinois4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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

• St. Coletta's of Illinois

  • Adult Mental Health Clinic/Center
  • Tinley Park, IL
  • NPI 1679279343
  NPD tax ID
• St. Coletta's of Illinois

  • Community/Behavioral Health Agency
  • Tinley Park, IL
  • NPI 1851184840
  NPD tax ID
• St. Coletta's of Illinois, Inc.

  • Developmentally Disabled Services Day Training Agency
  • Tinley Park, IL
  • NPI 1295195295
  NPD tax ID

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

{
    "created_epoch": "1201737600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1648684800000",
    "number": "1154509289",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "18350 CROSSING DR",
            "city": "TINLEY PARK",
            "state": "IL",
            "postal_code": "604876294",
            "telephone_number": "708-342-5200",
            "fax_number": "708-429-7021"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4900 183RD ST",
            "city": "COUNTRY CLUB HILLS",
            "state": "IL",
            "postal_code": "604784568",
            "telephone_number": "708-647-0752",
            "fax_number": "708-342-2579"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. COLETTA'S OF ILLINOIS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-01-31",
        "last_updated": "2022-03-31",
        "certification_date": "2022-03-31",
        "status": "A",
        "authorized_official_last_name": "SKAFGAARD",
        "authorized_official_first_name": "ANNETTE",
        "authorized_official_title_or_position": "DIRECTOR OF FINANCE",
        "authorized_official_telephone_number": "708-342-5253",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "CPA"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Country Club Terrace",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Country Club Terrace",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Diane Simpson, EDD
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• Verma L. Smith, BCBA
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• Tiffany Stingley
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• Intellectual Disabilities Intermediate Care Facility in Country Club Hills, IL
• Providers in Country Club Hills, IL by specialty
• Intellectual Disabilities Intermediate Care Facility in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 31, 2022; 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.