Healthcare Provider Details

I. General information

NPI: 1134105836
Provider Name (Legal Business Name): AUTUMN CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 01/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 LOLA AVE
ALTAVISTA VA
24517-1352
US

IV. Provider business mailing address

26691 RICHMOND RD
BEDFORD HEIGHTS OH
44146-1421
US

V. Phone/Fax

Practice location:
  • Phone: 434-369-6651
  • Fax: 434-309-7254
Mailing address:
  • Phone: 216-292-5706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License NumberNH2483
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH2483
License Number StateVA

VIII. Authorized Official

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