Healthcare Provider Details

I. General information

NPI: 1205833175
Provider Name (Legal Business Name): AUTUMN WOODS RESIDENTIAL HEALTH CARE FACILITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29800 HOOVER RD
WARREN MI
48093-3483
US

IV. Provider business mailing address

29800 HOOVER RD
WARREN MI
48093-3483
US

V. Phone/Fax

Practice location:
  • Phone: 158-657-4344
  • Fax: 586-574-9548
Mailing address:
  • Phone: 158-657-4344
  • Fax: 586-574-9548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number504240
License Number StateMI

VIII. Authorized Official

Name: MRS. ELIZABETH J WOLF
Title or Position: ADMINISTRATOR/VICE PRESIDENT
Credential: RN
Phone: 586-574-3444