Healthcare Provider Details

I. General information

NPI: 1174675342
Provider Name (Legal Business Name): AUTUMN BLESSINGS ASSISTD LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SUNSET
LOGAN NM
88426-9681
US

IV. Provider business mailing address

400 SUNSET
LOGAN NM
88426-9681
US

V. Phone/Fax

Practice location:
  • Phone: 575-487-2300
  • Fax: 575-487-2302
Mailing address:
  • Phone: 575-487-2300
  • Fax: 575-487-2302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number5869
License Number StateNM

VIII. Authorized Official

Name: MRS. KEN D WILLIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 575-487-2300