Healthcare Provider Details

I. General information

NPI: 1457556458
Provider Name (Legal Business Name): AUTUMN WIND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 W PINEWOOD ST
ROSEBORO NC
28382-5259
US

IV. Provider business mailing address

507 W PINEWOOD ST
ROSEBORO NC
28382-5259
US

V. Phone/Fax

Practice location:
  • Phone: 910-525-4082
  • Fax: 910-525-4059
Mailing address:
  • Phone: 910-525-4082
  • Fax: 910-525-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberHAL082012
License Number StateNC

VIII. Authorized Official

Name: MR. JESSE CHAD STEWART
Title or Position: ADMINISTRATOR
Credential:
Phone: 910-525-4082