- Enrollment id
- O20100527000772
- Enrollment state
- WI
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1205833175
- Multiple npi flag
- N
- Ccn
- 235427
- Associate id
- 8022146653
- Organization name
- AUTUMN WOODS RESIDENTIAL HEALTH CARE FACILITY LLC
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- AUTUMN WOODS RESIDENTIAL HEALTH
- Address line 1
- 29800 HOOVER RD
- City
- WARREN
- State
- MI
- Zip code
- 480933483