- Enrollment id
- O20220913000237
- Enrollment state
- MD
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1538818695
- Multiple npi flag
- N
- Ccn
- 215209
- Associate id
- 3870978836
- Organization name
- 6116 BELAIR ROAD OPCO LLC
- Incorporation date
- 2022-06-01
- Incorporation state
- MD
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- AUTUMN LAKE HEALTHCARE AT OVERLEA
- Affiliation entity name
- AUTUMN LAKE HEALTHCARE
- Affiliation entity id
- 56
- Address line 1
- 6116 BELAIR RD
- City
- BALTIMORE
- State
- MD
- Zip code
- 212061927