Provider Demographics
NPI:1174794580
Name:AUTUMN CORPORATION
Entity type:Organization
Organization Name:AUTUMN CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:252-443-6265
Mailing Address - Street 1:307 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:DREXEL
Mailing Address - State:NC
Mailing Address - Zip Code:28619-1278
Mailing Address - Country:US
Mailing Address - Phone:828-433-6180
Mailing Address - Fax:828-433-6672
Practice Address - Street 1:307 OAKLAND AVE.
Practice Address - Street 2:
Practice Address - City:DREXEL
Practice Address - State:NC
Practice Address - Zip Code:28619-1278
Practice Address - Country:US
Practice Address - Phone:828-433-6180
Practice Address - Fax:828-433-6672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0347313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406277Medicaid