- Enrollment id
- O20240625000521
- Enrollment state
- NJ
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1013786417
- Multiple npi flag
- N
- Ccn
- 315513
- Associate id
- 1759824261
- Organization name
- 113 SOUTH ROUTE 73 OPCO LLC
- Doing business as name
- THE SUBACUTE AT AUTUMN LAKE HEALTHCARE
- Incorporation date
- 2024-02-01
- Incorporation state
- NJ
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- THE SUBACUTE AT AUTUMN LAKE HEALTHCARE
- Affiliation entity name
- AUTUMN LAKE HEALTHCARE
- Affiliation entity id
- 56
- Address line 1
- 113 ROUTE 73
- City
- VOORHEES
- State
- NJ
- Zip code
- 080439573