Country Club Center Homes, Inc
Organization Active NPI Skilled Nursing Facility · Dover, OH
NPI 1821178427 · NPPES record last updated Aug 22, 2020
Key facts
- NPI
- 1821178427
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Skilled Nursing Facility 314000000X
- License
- 2499 (OH)
- Legal business name
- COUNTRY CLUB CENTER HOMES, INC
- Practice address
- 860 E Iron Ave
Dover, OH 44622-2031 - Phone
- (330) 343-5568
- Fax
- (330) 343-0514
- NPI assigned
- Oct 17, 2006
- Organization subpart
- No
Authorized official
- Name
- Mr. Michael M Hohman
- Title
- Administrator
- Phone
- (330) 343-5568
Corporate family (same tax ID) 1
Practitioners 4
-
Dirk N Juschka, MD
Affiliated clinicians 3
Medicare Care Compare: Nursing home
- Listed as
- Country Club Center I
- Overall star rating
- ★★☆☆☆ 2 of 5
- Health inspections
- ★☆☆☆☆ 1 of 5
- Staffing
- ★☆☆☆☆ 1 of 5
- Quality measures
- ★★★★★ 5 of 5
- Type
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Certified
- May 1, 1979
- Medicare certification status
- Active
- Certified beds
- 72 · 55.9 residents per day on average
- Chain
- Country Club Rehabilitation Campus
- Special focus status
- SFF Candidate
- Abuse citation
- Cited for abuse (Care Compare abuse icon)
- Penalties (3 years)
- 5 · fines totaling $193,787
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 36D0900995 | Country Club Retirement Campus | Certificate of waiver | May 11, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in OH
Skilled nursing facility certification: CCN 365417
- Legal name
- COUNTRY CLUB CENTER HOMES, INC
- Doing business as
- COUNTRY CLUB RETIREMENT CAMPUS
- Certification status
- Active
- Provider type (POS)
- Nursing home – SNF/NF dual certification
- Participating since
- May 1, 1979
- Last certification
- Dec 2, 2024
- Beds
- 72
- Ownership / control type
- Limited Liability Corporation
- Organization structure
- Corporation · Proprietary
- Incorporated
- Mar 26, 1976 in OH
- Enrollment address
- 860 E Iron Ave
Dover, OH 44622-2031 - Nursing home name
- COUNTRY CLUB CENTER I
- Affiliated entity
- COUNTRY CLUB REHABILITATION CAMPUS
All disclosed owners & managing parties 6
| Name | Role | Since | Share |
|---|---|---|---|
| John Holland |
5% Or Greater Direct Ownership Interest | Feb 17, 1976 | 50% |
| Corporate Officer | May 1, 2002 | 50% | |
| Adp of the SNF | Dec 10, 2024 | ||
| |
Adp of the SNF | Dec 10, 2024 | |
| Teresa Holland-Grescock |
5% Or Greater Direct Ownership Interest | May 1, 2002 | 50% |
| Corporate Officer | May 1, 2002 | 50% | |
| Adp of the SNF | Dec 10, 2024 | ||
| Direct Ownership Interest | May 1, 2002 | 50% | |
| Paul Lieber |
W-2 Managing Employee |
Jul 1, 2024 | 75% |
| Operational/Managerial Control | Nov 18, 2024 | ||
| Adp of the SNF | Dec 10, 2024 | ||
| Janet Harris |
Corporate Officer |
Jan 1, 2008 | |
| Corporate Director |
Jan 1, 2008 | 100% | |
| Operational/Managerial Control | Nov 6, 2024 | ||
| Adp of the SNF | Dec 10, 2024 | ||
| |
Adp of the SNF | Dec 10, 2024 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040226000133 | OH | Part a Provider - Skilled Nursing Facility | 1850287855 | Practice locations: Dover, OH |
National Provider Directory
- Tax ID family
- Country Club Center Homes Inc
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Skilled Nursing Facility | 314000000X | 2499 | OH | Yes |
Addresses
Primary practice location
860 E Iron Ave
Dover, OH 44622-2031
Mailing address
860 E Iron Ave
Dover, OH 44622-2031
Phone (330) 343-5568
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0400828 | Medicaid | OH |
Other providers in Dover, OH
- Brandy L Cooley-Debolt
- Kelly Lee Corbin
- Margaret Corp
- Christopher Coulson
- Country Club Center Homes, Inc
- Deborah R. Cowden
- Thomas J Cox
- Kelly Rae Dallas
- Dasco-Union Hospital Home Medical Equipment
- Alicia A Daugherty
All providers in Dover, OH · Skilled Nursing Facility in Ohio
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 22, 2020. 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.