Country Aire Healthcare LLC
Organization Active NPI Skilled Nursing Facility · Lewistown, MO
NPI 1619639192 · NPPES record last updated Oct 12, 2021
Key facts
- NPI
- 1619639192
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Skilled Nursing Facility 314000000X
- Legal business name
- COUNTRY AIRE HEALTHCARE LLC
- Practice address
- 18540 State Highway 16
Lewistown, MO 63452-2111 - Phone
- (573) 215-2216
- NPI assigned
- Oct 12, 2021
- Organization subpart
- No
Authorized official
- Name
- Bernard David Perlow
- Title
- Authorized Person
- Phone
- (443) 928-3278
Facilities with the same owner 7
Practitioners 3
-
Michael D Jones, MD
-
Hans James Raj, MD
Affiliated clinicians 3
-
Arvin Garcia Abueg, M.D.
-
Michael D Jones, MD
Medicare Care Compare: Nursing home
- Listed as
- Country Aire Retirement Center
- Overall star rating
- ★☆☆☆☆ 1 of 5
- Health inspections
- ★☆☆☆☆ 1 of 5
- Staffing
- ★☆☆☆☆ 1 of 5
- Quality measures
- ★★★☆☆ 3 of 5
- Type
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Certified
- Nov 14, 1991
- Medicare certification status
- Active
- Certified beds
- 60 · 38.9 residents per day on average
- Penalties (3 years)
- 1 · fines totaling $0
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 26D0441501 | Country Aire Healthcare | Certificate of waiver | Aug 31, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MO
Skilled nursing facility certification: CCN 265474
- Legal name
- COUNTRY AIRE HEALTHCARE LLC
- Doing business as
- COUNTRY AIRE RETIREMENT CENTER
- Certification status
- Active
- Provider type (POS)
- Nursing home – SNF/NF dual certification
- Participating since
- Nov 14, 1991
- Last certification
- Jul 11, 2024
- Beds
- 60
- Ownership / control type
- Limited Liability Corporation
- Most recent change of ownership
- Aug 31, 2021
- Organization structure
- LLC · Proprietary
- Incorporated
- Dec 17, 2020 in MO
- Enrollment address
- 18540 State Highway 16
Lewistown, MO 63452-2111
All disclosed owners & managing parties 9
| Name | Role | Since | Share |
|---|---|---|---|
| David Yitzchok Kleiner |
5% Or Greater Indirect Ownership Interest | Aug 31, 2021 | 10.2% |
| Dkyh Missouri LLC |
5% Or Greater Direct Ownership Interest | Aug 31, 2021 | |
| Samuel Stern |
Corporate Officer |
Jan 1, 2023 | |
| Martha Bogguss |
W-2 Managing Employee |
Aug 31, 2021 | |
| Sloans Lake Trust |
5% Or Greater Indirect Ownership Interest | Aug 31, 2021 | 63.33% |
| Blue Sky Basin LLC |
5% Or Greater Direct Ownership Interest | Aug 31, 2021 | 66.66% |
| Bernard David Perlow |
5% Or Greater Indirect Ownership Interest | Aug 31, 2021 | 23.1% |
| Corporate Director |
Aug 31, 2021 | ||
| Eliot Berger |
Corporate Director |
Aug 31, 2021 | |
| Other |
Aug 31, 2021 | ||
| DKDP Missouri LLC |
5% Or Greater Direct Ownership Interest | Aug 31, 2021 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20211001001710 | MO | Part a Provider - Skilled Nursing Facility | 4082012216 | Practice locations: Lewistown, MO |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Skilled Nursing Facility | 314000000X | Yes |
Addresses
Primary practice location
18540 State Highway 16
Lewistown, MO 63452-2111
Mailing address
110 Rockaway Tpke Ste 6
Lawrence, NY 11559-1626
Other names
- Country Aire Retirement Center
NPI Registry JSON
{
"created_epoch": "1633996800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1633996800000",
"number": "1619639192",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "110 ROCKAWAY TPKE STE 6",
"city": "LAWRENCE",
"state": "NY",
"postal_code": "115591626"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "18540 STATE HIGHWAY 16",
"city": "LEWISTOWN",
"state": "MO",
"postal_code": "634522111",
"telephone_number": "573-215-2216"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "COUNTRY AIRE HEALTHCARE LLC",
"organizational_subpart": "NO",
"enumeration_date": "2021-10-12",
"last_updated": "2021-10-12",
"certification_date": "2021-09-27",
"status": "A",
"authorized_official_last_name": "PERLOW",
"authorized_official_first_name": "BERNARD",
"authorized_official_middle_name": "DAVID",
"authorized_official_title_or_position": "AUTHORIZED PERSON",
"authorized_official_telephone_number": "443-928-3278"
},
"taxonomies": [
{
"code": "314000000X",
"taxonomy_group": "",
"desc": "Skilled Nursing Facility",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"organization_name": "Country Aire Retirement Center",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Lewistown, MO
- Anita Lyn Arnold
- Penny Elizabeth Buening
- Karen Joy Abando Cordova
- Country Aire Opco, LLC
- Country Aire Operations Management LLC
- Deaconess Long Term Care of Missouri, Inc.
- Michelle Ebeling
- GX2 LLC
All providers in Lewistown, MO · Skilled Nursing Facility in Missouri
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 12, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.