MEDICARE: AUTUMN COURT HEALTHCARE CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1093651838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUTUMN COURT HEALTHCARE CENTER LLC

Provider Business Mailing Address
First Line	:	917 BROADWAY
Second Line	:
City	:	HANNIBAL
State	:	MO
Zip	:	63401-4200
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1421 S LANDRUM ST
Second Line	:
City	:	MOUNT VERNON
State	:	MO
Zip	:	65712-1912
Country	:	US
Telephone Number	:	417-466-2549
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JOSHUA WILLIAMS
Credential	:
Telephone Number	:	573-795-5012

Provider Enumeration Date	:	04/24/2026
Last Update Date	:	04/24/2026

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