Basic Information
| Provider Information | |||||||||
| NPI: | 1346785144 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MS-AC MANKATO AG SENIOR LIVING LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AUTUMN GRACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 SPRING ST | ||||||||
| Address2: | STE 205 | ||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209103616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2405956064 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 118 RAVEN CT | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560018431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073885412 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2017 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SWEET | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 2405956064 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERISTAR ACAS HOLDINGS, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.