Provider Demographics
NPI:1205833175
Name:AUTUMN WOODS RESIDENTIAL HEALTH CARE FACILITY LLC
Entity Type:Organization
Organization Name:AUTUMN WOODS RESIDENTIAL HEALTH CARE FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:586-574-3444
Mailing Address - Street 1:29800 HOOVER RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3483
Mailing Address - Country:US
Mailing Address - Phone:158-657-4344
Mailing Address - Fax:586-574-9548
Practice Address - Street 1:29800 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3483
Practice Address - Country:US
Practice Address - Phone:158-657-4344
Practice Address - Fax:586-574-9548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-06
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI504240314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2155021Medicaid
MI2155021Medicaid