Healthcare Provider Details

I. General information

NPI: 1114463932
Provider Name (Legal Business Name): AUTUMN CARE OF FAYETTEVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 71ST SCHOOL RD
FAYETTEVILLE NC
28314-2814
US

IV. Provider business mailing address

23700 COMMERCE PARK
BEACHWOOD OH
44122-5827
US

V. Phone/Fax

Practice location:
  • Phone: 910-867-4960
  • Fax: 910-867-4980
Mailing address:
  • Phone: 216-292-5706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM I WEISBERG
Title or Position: PRESIDENT
Credential:
Phone: 216-292-5706