NPIMap

Organization Active NPI

Countryside Nursing and Rehabilitation Center LLC

  • Skilled Nursing Facility
  • Dolton, IL
National Provider Identifier
1386966919
Registry record updated Feb 24, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
0050708 Issued in IL
Legal business name
COUNTRYSIDE NURSING AND REHABILITATION CENTER LLC
Practice address
1635 E 154TH St
Dolton, IL 60419-3001
Phone
(708) 841-9550
Fax
(708) 841-4517
NPI assigned
Feb 24, 2010
Last updated
Feb 24, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 24, 2010

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

Authorized official

Name
Mr. Joe Zimmerman
Title
Ceo
Phone
(847) 905-4000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 0050708 IL Primary

Addresses

Primary practice location

1635 E 154TH St
Dolton, IL 60419-3001

Mailing address

1635 E 154TH St
Dolton, IL 60419-3001
Phone (708) 841-9550

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100322000781 IL Part A Provider - Skilled Nursing Facility 1759416266 Practice locations: Dolton, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1386966919. Details of each certification follow.

Skilled nursing facility certification: CCN 145798

Legal name
COUNTRYSIDE NURSING AND REHABILITATION CENTER LLC
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF distinct part
Participating since
Aug 1, 1994
Last certification
Sep 13, 2024
Beds
197
Ownership / control type
Individual
Organization structure
LLCProprietary
Incorporated
Sep 18, 2009 in IL
Enrollment address
1635E 154TH St
Dolton, IL 60419-3001
Nursing home name
COUNTRYSIDE NURSING & REHAB CTR
Affiliated entity
EXTENDED CARE CLINICAL

Care Compare: Nursing home

Medicare Care Compare
Listed as
Countryside Nursing & Rehab CtrCCN 145798 · All quality measures
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 - Individual
Certified
Aug 1, 1994
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
197143.9 residents per day on average
Chain
Extended Care Clinical9 facilities in the chain
Penalties (3 years)
1Fines totaling $0

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
B & Z Grandchildren TR Organization, Evanston, IL Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jan 1, 2015 10%
Extended Care Clinical LLC Organization, Evanston, IL LLC Adp of the SNF Jan 1, 2015
Chandra S Anand Individual Adp of the SNF Jul 30, 2015
Roth & Co, LLP Organization, Brooklyn, NY Adp of the SNF Jan 1, 2025
N & S Rothner Trust Organization, Evanston, IL Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jan 1, 2015 88%
Adp of the SNF Jan 1, 2015
Eric Rothner Individual Corporate OfficerManager Nov 1, 2009 2%
Aasta Merritt-James Individual Operational/Managerial Control Jul 30, 2015
Adp of the SNF Jul 30, 2015
David Aronin Individual Corporate OfficerManager Mar 3, 2010

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 4

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": "1266969600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1266969600000",
    "number": "1386966919",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1635 E 154TH ST",
            "city": "DOLTON",
            "state": "IL",
            "postal_code": "604193001",
            "telephone_number": "708-841-9550",
            "fax_number": "708-841-4517"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1635 E 154TH ST",
            "city": "DOLTON",
            "state": "IL",
            "postal_code": "604193001",
            "telephone_number": "708-841-9550",
            "fax_number": "708-841-4517"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRYSIDE NURSING AND REHABILITATION CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-02-24",
        "last_updated": "2010-02-24",
        "status": "A",
        "authorized_official_last_name": "ZIMMERMAN",
        "authorized_official_first_name": "JOE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "847-905-4000",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "IL",
            "license": "0050708",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Dolton, IL

Sources for this page

Verify at the official NPI Registry.