- Enrollment id
- O20210610003415
- Enrollment state
- MD
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1912583683
- Multiple npi flag
- N
- Ccn
- 215148
- Associate id
- 1355741463
- Organization name
- 1221 WAUGH CHAPEL OPCO LLC
- Doing business as name
- AUTUMN LAKE HEALTHCARE AT WAUGH CHAPEL
- Incorporation date
- 2020-12-29
- Incorporation state
- MD
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- AUTUMN LAKE HEALTHCARE AT WAUGH CHAPEL
- Affiliation entity name
- AUTUMN LAKE HEALTHCARE
- Affiliation entity id
- 56
- Address line 1
- 1221 WAUGH CHAPEL RD
- City
- GAMBRILLS
- State
- MD
- Zip code
- 210541608