Healthcare Provider Details

I. General information

NPI: 1366188112
Provider Name (Legal Business Name): AUTUMN CARE OF SUFFOLK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 05/05/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 PRUDEN BLVD
SUFFOLK VA
23434-4229
US

IV. Provider business mailing address

1 SACRAMENTO DR APT 65
HAMPTON VA
23666-1677
US

V. Phone/Fax

Practice location:
  • Phone: 757-934-2363
  • Fax:
Mailing address:
  • Phone: 540-497-3245
  • 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: MISS LIANA GLORIA ELYSEE
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential:
Phone: 540-497-3245