Healthcare Provider Details

I. General information

NPI: 1497170260
Provider Name (Legal Business Name): AUTUMN VIEW OUTREACH AND DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2014
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 LEGG DR
GULFPORT MS
39503-3352
US

IV. Provider business mailing address

PO BOX 3162
GULFPORT MS
39505-3162
US

V. Phone/Fax

Practice location:
  • Phone: 228-547-4424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number03873054
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number01541356
License Number StateMS

VIII. Authorized Official

Name: KWANTRELL GREEN
Title or Position: PRESIDENT
Credential:
Phone: 228-547-4424