1134105836 NPI number — AUTUMN CORPORATION

Table of content: (NPI 1134105836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134105836 NPI number — AUTUMN CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUTUMN CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AUTUMN CARE OF ALTAVISTA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134105836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26691 RICHMOND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEDFORD HEIGHTS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44146-1421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-292-5706
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1317 LOLA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTAVISTA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24517-1352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-369-6651
Provider Business Practice Location Address Fax Number:
434-309-7254
Provider Enumeration Date:
12/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WEISBERG
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
I.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
216-292-5706

Provider Taxonomy Codes

  • Taxonomy code: 311Z00000X , with the licence number:  NH2483 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: NH2483 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4951964 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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