- Enrollment id
- O20180712002768
- Enrollment state
- MD
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1629572508
- Multiple npi flag
- N
- Ccn
- 215177
- Associate id
- 4284980707
- Organization name
- CHERRY LANE OPERATING GROUP LLC
- Doing business as name
- AUTUMN LAKE HEALTHCARE AT CHERRY LANE
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- AUTUMN LAKE HEALTHCARE AT CHERRY LANE
- Affiliation entity name
- AUTUMN LAKE HEALTHCARE
- Affiliation entity id
- 56
- Address line 1
- 9001 CHERRY LN
- City
- LAUREL
- State
- MD
- Zip code
- 207081120