Provider Demographics
NPI:1366188112
Name:AUTUMN CARE OF SUFFOLK
Entity type:Organization
Organization Name:AUTUMN CARE OF SUFFOLK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:LIANA
Authorized Official - Middle Name:GLORIA
Authorized Official - Last Name:ELYSEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-497-3245
Mailing Address - Street 1:1 SACRAMENTO DR APT 65
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1677
Mailing Address - Country:US
Mailing Address - Phone:540-497-3245
Mailing Address - Fax:
Practice Address - Street 1:2580 PRUDEN BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4229
Practice Address - Country:US
Practice Address - Phone:757-934-2363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility