1205833175 NPI number — AUTUMN WOODS RESIDENTIAL HEALTH CARE FACILITY LLC

Table of content: (NPI 1205833175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205833175 NPI number — AUTUMN WOODS RESIDENTIAL HEALTH CARE FACILITY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUTUMN WOODS RESIDENTIAL HEALTH CARE FACILITY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205833175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29800 HOOVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48093-3483
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
158-657-4344
Provider Business Mailing Address Fax Number:
586-574-9548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29800 HOOVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48093-3483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
158-657-4344
Provider Business Practice Location Address Fax Number:
586-574-9548
Provider Enumeration Date:
07/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WOLF
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
J
Authorized Official Title or Position:
ADMINISTRATOR/VICE PRESIDENT
Authorized Official Telephone Number:
586-574-3444

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  504240 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2155021 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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