Country Club Retirement Center IV, Inc

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

3761 Issued in OH

Legal business name

COUNTRY CLUB RETIREMENT CENTER IV, INC

Practice address

55801 Conno Mara Dr
Bellaire, OH 43906-9698

Phone

(800) 516-9389

Fax

(740) 676-1277

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 365699

Legal name

COUNTRY CLUB RETIREMENT CENTER IV, INC

Certification status

Active

Provider type (POS)

Nursing home – SNF/NF dual certification

Participating since

Jun 23, 1987

Last certification

Sep 30, 2024

Beds

62

Ownership / control type

Limited Liability Corporation

Organization structure

LLCProprietary

Incorporated

May 1, 1989 in OH

Enrollment address

55801 Conno Mara Dr
Bellaire, OH 43906-9698

Nursing home name

COUNTRY CLUB RETIREMENT CTR IV

Affiliated entity

COUNTRY CLUB REHABILITATION CAMPUS

Listed as

Country Club Retirement Ctr IVCCN 365699

Overall star rating

1 of 5

Health inspections

1 of 5

Staffing

1 of 5

Quality measures

4 of 5

Type

Medicare and Medicaid

Ownership

For profit - Limited Liability company

Certified

Jun 23, 1987

Medicare certification status

ActiveFrom the Provider of Services file

Certified beds

6242.6 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

Country Club Retirement Center IV Inc2 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 IV, Inc

  • Assisted Living Facility
  • Bellaire, OH
  • NPI 1447841572
  NPD tax ID

All disclosed owners & managing parties 13

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.

• Zaveen Ahmad Kureishy, M.D.

  • Internal Medicine Physician
  • Glen Dale, WV
  • NPI 1467455915

  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 LLC

  • Skilled Nursing Facility
  • Ashtabula, OH
  • NPI 1144372137

  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.

• Renato F Delacruz, MD

  • Internal Medicine Physician
  • Saint Clairsville, OH
  • NPI 1174523641
  NPD (past)
• Zaveen Ahmad Kureishy, M.D.

  • Internal Medicine Physician
  • Glen Dale, WV
  • NPI 1467455915
  NPD (past)

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

{
    "created_epoch": "1169078400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1334534400000",
    "number": "1881747673",
    "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": "55801 CONNO MARA DR",
            "city": "BELLAIRE",
            "state": "OH",
            "postal_code": "439069698",
            "telephone_number": "800-516-9389",
            "fax_number": "740-676-1277"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY CLUB RETIREMENT CENTER IV, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-18",
        "last_updated": "2012-04-16",
        "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": "1858R",
            "primary": false
        },
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "OH",
            "license": "3761",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0640051",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM",
            "identifier": "000000335475",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Angela Marie Clifford
• Lacey Lauren Clymer
• Marcy Jo Cochran, RN
• Douglas Michael Conner
• Country Club Retirement Center IV, Inc
• Dean'S Natural Wellness
• McKenzie Deese, CPST
• Amanda Marie Dickson, PHARM.D.
• Katie Dicola, BCBA
• Mikayla Dinapoli, CDCAII

• Skilled Nursing Facility in Bellaire, OH
• Providers in Bellaire, 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 16, 2012; 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.