Provider Demographics
NPI:1487167805
Name:AUTUMN PARK INC
Entity type:Organization
Organization Name:AUTUMN PARK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:R
Authorized Official - Last Name:JACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-275-4458
Mailing Address - Street 1:PO BOX 911415
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84791-1415
Mailing Address - Country:US
Mailing Address - Phone:435-275-4458
Mailing Address - Fax:
Practice Address - Street 1:548 N 1100 E
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-2980
Practice Address - Country:US
Practice Address - Phone:435-275-4458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT000820310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility