Provider Demographics
NPI:1255475786
Name:AUTUMN PARK ASST LIVING
Entity Type:Organization
Organization Name:AUTUMN PARK ASST LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-485-4600
Mailing Address - Street 1:PO BOX 3006
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-0006
Mailing Address - Country:US
Mailing Address - Phone:503-485-4600
Mailing Address - Fax:
Practice Address - Street 1:5045 W 52ND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-1705
Practice Address - Country:US
Practice Address - Phone:317-293-2929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility