Provider Demographics
NPI:1265799829
Name:DREAMSHINE AT AUTUMN LAKES LLC
Entity type:Organization
Organization Name:DREAMSHINE AT AUTUMN LAKES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:E
Authorized Official - Last Name:MINARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-226-9105
Mailing Address - Street 1:3821 BLUE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SUNBURY
Mailing Address - State:OH
Mailing Address - Zip Code:43074-8922
Mailing Address - Country:US
Mailing Address - Phone:614-226-9105
Mailing Address - Fax:
Practice Address - Street 1:3821 BLUE CHURCH RD
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:OH
Practice Address - Zip Code:43074-8922
Practice Address - Country:US
Practice Address - Phone:614-226-9105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2727115Medicaid