Healthcare Provider Details

I. General information

NPI: 1376590810
Provider Name (Legal Business Name): AUTUMN COUNTRY CLUB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N REED ST
JOLIET IL
60435-6825
US

IV. Provider business mailing address

107 N REED ST
JOLIET IL
60435-6825
US

V. Phone/Fax

Practice location:
  • Phone: 815-730-0060
  • Fax: 815-741-0943
Mailing address:
  • Phone: 815-730-0060
  • Fax: 815-741-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberADS1102001
License Number StateIL

VIII. Authorized Official

Name: MS. M CATHERINE WATERMAN
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 815-730-0060