- Enrollment id
- O20180605000286
- Enrollment state
- MD
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1831696509
- Multiple npi flag
- N
- Ccn
- 215195
- Associate id
- 6608131198
- Organization name
- BRIDGEPARK OPERATIONS, LLC
- Doing business as name
- AUTUMN LAKE HEALTHCARE AT BRIDGEPARK
- Incorporation date
- 2018-02-12
- Incorporation state
- NJ
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- AUTUMN LAKE HEALTHCARE AT BRIDGEPARK
- Affiliation entity name
- AUTUMN LAKE HEALTHCARE
- Affiliation entity id
- 56
- Address line 1
- 4017 LIBERTY HEIGHTS AVE
- City
- BALTIMORE
- State
- MD
- Zip code
- 212077545