Provider Demographics
NPI:1437693785
Name:KING DAVID AT AUTUMN LAKE LLC
Entity Type:Organization
Organization Name:KING DAVID AT AUTUMN LAKE LLC
Other - Org Name:KING DAVID NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ARYEH
Authorized Official - Middle Name:
Authorized Official - Last Name:STERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-358-6883
Mailing Address - Street 1:4204 OLD MILFORD MILL RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-6031
Mailing Address - Country:US
Mailing Address - Phone:410-486-1500
Mailing Address - Fax:
Practice Address - Street 1:4204 OLD MILFORD MILL RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-6031
Practice Address - Country:US
Practice Address - Phone:410-486-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03024314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD215022Medicare Oscar/Certification