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General NPI Number Information
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NPI Number | 1497170260
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Entity Type | Organization
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Legal Business Name | AUTUMN VIEW OUTREACH AND DEVELOPMENT
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Dates
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Enumeration Date | 03/03/2014
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Last Update Date | 03/03/2014
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Provider Practice Location Address
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Address Line | 400 LEGG DR
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City | GULFPORT
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State | MS
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Zip | 39503-3352
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Country | US
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Telephone | 228-547-4424
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3162
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City | GULFPORT
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State | MS
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Zip | 39505-3162
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | KWANTRELL GREEN
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Credential |
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Telephone | 228-547-4424
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 01541356
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License Number State | MS
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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 | 03873054
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License Number State | MS
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