NPIMap

Organization Active NPI

Countryside Manor Nursing and Rehabilitation LLC

  • Skilled Nursing Facility
  • Fremont, OH
National Provider Identifier
1952887549
Registry record updated Jul 17, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
2362N Issued in OH
Legal business name
COUNTRYSIDE MANOR NURSING AND REHABILITATION LLC
Practice address
1865 Countryside Dr
Fremont, OH 43420-8748
Phone
(419) 334-2602
Fax
(419) 344-6287
NPI assigned
Jul 17, 2018
Last updated
Jul 17, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 17, 2018

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

Authorized official

Name
Hayley Williams
Title
Attorney
Phone
(216) 706-3936

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 2362N OH Primary

Addresses

Primary practice location

1865 Countryside Dr
Fremont, OH 43420-8748

Mailing address

15 America Ave Unit 304
Lakewood, NJ 08701-4582
Phone (513) 487-7479

Other identifiers 1

IdentifierTypeStateIssuer
2362NOtherOHLICENSURE

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20181018003192 OH Part A Provider - Skilled Nursing Facility 5496008518 Practice locations: Fremont, OH

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1952887549. Details of each certification follow.

Skilled nursing facility certification: CCN 365418

Legal name
COUNTRYSIDE MANOR NURSING AND REHABILITATION LLC
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
May 29, 1979
Last certification
Jun 3, 2025
Beds
82
Ownership / control type
Limited Liability Corporation
Multi-facility organization
CCH Healthcare
Organization structure
LLCProprietary
Incorporated
May 8, 2018 in OH
Enrollment address
1865 Countryside Dr
Fremont, OH 43420-8748
Nursing home name
COUNTRYSIDE MANOR NURSING AND REHABILITATION LLC
Affiliated entity
CCH HEALTHCARE

Care Compare: Nursing home

Medicare Care Compare
Listed as
Countryside Manor Nursing and Rehabilitation LLCCCN 365418 · All quality measures
Overall star rating
1 of 5
Health inspections
1 of 5
Staffing
3 of 5
Quality measures
4 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
May 29, 1979
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
8273.0 residents per day on average
Chain
CCH Healthcare33 facilities in the chain
Penalties (3 years)
3Fines totaling $59,623

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Capital Holdings Trust Organization, Lakewood, NJ 5% Or Greater Indirect Ownership Interest Aug 1, 2018 95%
Starlight Healthcare LLC Organization, Lakewood, NJ Created for acquisition, LLC 5% Or Greater Direct Ownership Interest Aug 1, 2018 12.5%
Fremont Holdings TR Organization, Lakewood, NJ 5% Or Greater Direct Ownership Interest Aug 1, 2018 87.5%
Jacob Stern Individual 5% Or Greater Indirect Ownership InterestManaging Member Aug 1, 2018 5%
Corporate OfficerPresident Aug 1, 2018 100%
Corporate DirectorSole Director Aug 1, 2018 100%
W-2 Managing EmployeeManager Aug 1, 2018 100%
OtherTrustee Aug 1, 2018 87.5%

Facilities with the same owner 30

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 30

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

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": "1531785600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1531785600000",
    "number": "1952887549",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "15 AMERICA AVE UNIT 304",
            "city": "LAKEWOOD",
            "state": "NJ",
            "postal_code": "087014582",
            "telephone_number": "513-487-7479"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1865 COUNTRYSIDE DR",
            "city": "FREMONT",
            "state": "OH",
            "postal_code": "434208748",
            "telephone_number": "419-334-2602",
            "fax_number": "419-344-6287"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRYSIDE MANOR NURSING AND REHABILITATION LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-07-17",
        "last_updated": "2018-07-17",
        "status": "A",
        "authorized_official_last_name": "WILLIAMS",
        "authorized_official_first_name": "HAYLEY",
        "authorized_official_title_or_position": "ATTORNEY",
        "authorized_official_telephone_number": "216-706-3936"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "OH",
            "license": "2362N",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSURE",
            "identifier": "2362N",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fremont, OH

Sources for this page

Verify at the official NPI Registry.