- Enrollment id
- O20170324001957
- Enrollment state
- MD
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1437693785
- Multiple npi flag
- N
- Ccn
- 215022
- Associate id
- 7315222841
- Organization name
- KING DAVID AT AUTUMN LAKE LLC
- Doing business as name
- KING DAVID NURSING AND REHABILITATION CENTER
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- KING DAVID NURSING AND REHABILITATION CENTER
- Affiliation entity name
- AUTUMN LAKE HEALTHCARE
- Affiliation entity id
- 56
- Address line 1
- 4204 OLD MILFORD MILL RD
- City
- BALTIMORE
- State
- MD
- Zip code
- 212086031