- Enrollment id
- O20211201002443
- Enrollment state
- MD
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1538736566
- Multiple npi flag
- N
- Ccn
- 215120
- Associate id
- 9436549607
- Organization name
- 2131 DAVIDSONVILLE OPCO, LLC
- Doing business as name
- AUTUMN LAKE HEALTHCARE AT CROFTON
- Incorporation date
- 2021-03-25
- Incorporation state
- MD
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- AUTUMN LAKE HEALTHCARE AT CROFTON
- Affiliation entity name
- AUTUMN LAKE HEALTHCARE
- Affiliation entity id
- 56
- Address line 1
- 2131 DAVIDSONVILLE RD
- City
- CROFTON
- State
- MD
- Zip code
- 211141632