Healthcare Provider Details

I. General information

NPI: 1821515719
Provider Name (Legal Business Name): AUTUMN WOODS RESIDENTIAL HEALTH CARE FACILITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 08/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29800 HOOVER RD
WARREN MI
48093-3483
US

IV. Provider business mailing address

560 DELAWARE SUITE 400
BUFFALO NY
14202-1204
US

V. Phone/Fax

Practice location:
  • Phone: 586-574-3444
  • Fax:
Mailing address:
  • Phone: 716-826-2257
  • Fax: 716-819-1540

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: ELIZABETH J WOLF
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 586-574-3444