Healthcare Provider Details

I. General information

NPI: 1730326380
Provider Name (Legal Business Name): AUTUM YEAR FAMILY CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2009
Last Update Date: 01/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 SURRY DR
SHELBY NC
28152-7140
US

IV. Provider business mailing address

430 TYSONS FOREST DR
ROCK HILL SC
29732-3805
US

V. Phone/Fax

Practice location:
  • Phone: 704-487-8261
  • Fax:
Mailing address:
  • Phone: 803-448-2611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ADEMOLA A SALAMI
Title or Position: OWNER
Credential: RN, CRNA
Phone: 803-448-2611