Provider Demographics
NPI:1447841572
Name:COUNTRY CLUB RETIREMENT CENTER IV, INC
Entity type:Organization
Organization Name:COUNTRY CLUB RETIREMENT CENTER IV, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-239-3597
Mailing Address - Street 1:55801 CONNO MARA DR
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:OH
Mailing Address - Zip Code:43906-9698
Mailing Address - Country:US
Mailing Address - Phone:740-676-2300
Mailing Address - Fax:
Practice Address - Street 1:55801 CONNO MARA DR
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:OH
Practice Address - Zip Code:43906-9698
Practice Address - Country:US
Practice Address - Phone:740-676-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1858ROtherLICENSURE