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General NPI Number Information
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NPI Number | 1891824892
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Entity Type | Organization
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Legal Business Name | AUTUMN LEAVES, INC.
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 01/23/2017
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Provider Practice Location Address
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Address Line | 3905 E. HICKORY ST.
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City | DECATUR
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State | IL
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Zip | 62521
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Country | US
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Telephone | 217-429-8231
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Fax |
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Provider Business Mailing Address
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Address Line | 2576 N GREENWAY RD
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City | CERRO GORDO
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State | IL
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Zip | 61818-3022
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Country | US
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Telephone | 217-763-2191
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Fax | 217-763-2101
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. DAVID MICHAEL JACOBUS
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Credential |
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Telephone | 217-763-2191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 37846
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License Number State | IL
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