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General NPI Number Information
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NPI Number | 1376590810
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Entity Type | Organization
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Legal Business Name | AUTUMN COUNTRY CLUB, INC.
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Dates
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Enumeration Date | 05/30/2006
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Last Update Date | 04/14/2016
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Provider Practice Location Address
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Address Line | 107 N REED ST
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City | JOLIET
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State | IL
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Zip | 60435-6825
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Country | US
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Telephone | 815-730-0060
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Fax | 815-741-0943
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Provider Business Mailing Address
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Address Line | 107 N REED ST
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City | JOLIET
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State | IL
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Zip | 60435-6825
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Country | US
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Telephone | 815-730-0060
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Fax | 815-741-0943
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MS. M CATHERINE WATERMAN
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Credential |
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Telephone | 815-730-0060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number | ADS1102001
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number |
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License Number State |
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