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General NPI Number Information
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NPI Number | 1477988558
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Entity Type | Organization
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Legal Business Name | AUTUMN WIND
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Dates
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Enumeration Date | 09/09/2013
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Last Update Date | 09/09/2013
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Provider Practice Location Address
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Address Line | 135 AUTUMN WIND CT
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City | MINEOLA
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State | TX
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Zip | 75773-0017
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Country | US
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Telephone | 903-569-1111
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Fax | 903-569-6007
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Provider Business Mailing Address
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Address Line | 135 AUTUMN WIND CT
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City | MINEOLA
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State | TX
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Zip | 75773-0017
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Country | US
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Telephone | 903-569-1111
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Fax | 903-569-6007
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. MELISSA G DYER
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Credential | L.V.N.
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Telephone | 903-434-9300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 105574
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License Number State | TX
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