Organization · NPI-2

115 East Melrose Opco LLC

Skilled Nursing Facility · Baltimore, MD

NPI number1043896814

StatusActive

Last updated in NPPESMar 22, 2021

Details

NPI: 1043896814
Entity type: Organization (NPI-2)
Legal business name: 115 East Melrose Opco LLC
Organization subpart: No
Enumeration date: Mar 22, 2021
Certification date: Mar 22, 2021
Last updated: Mar 22, 2021

Taxonomy and licenses

Taxonomy code	Description	License	State	Primary
314000000X	Skilled Nursing Facility	–	–	Yes
385H00000X	Respite Care	–	–
313M00000X	Nursing Facility/Intermediate Care Facility	–	–

Other names

Autumn Lake Healthcare At Long Green (Doing Business As)

Practice location

115 E Melrose Ave
Baltimore, MD 21212-2945

Phone 877-567-0402

Mailing address

14c 53rd St
Brooklyn, NY 11232-2644

Authorized official

Sam Stern
Cfo
8775670402

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