Healthcare Provider Details

I. General information

NPI: 1720284839
Provider Name (Legal Business Name): AUTUMN VIEW SENIOR DAY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14321 DEDEAUX RD SUITE 14
GULFPORT MS
39503-3369
US

IV. Provider business mailing address

14321 DEDEAUX RD SUITE 14
GULFPORT MS
39503-3369
US

V. Phone/Fax

Practice location:
  • Phone: 228-831-0048
  • Fax: 228-831-0058
Mailing address:
  • Phone: 228-831-0048
  • Fax: 228-831-0058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. KWANTRELL D GREEN
Title or Position: CEO MANAGER
Credential:
Phone: 228-343-9013