Provider Demographics
NPI:1376590810
Name:AUTUMN COUNTRY CLUB, INC.
Entity Type:Organization
Organization Name:AUTUMN COUNTRY CLUB, INC.
Other - Org Name:AUTUMN ADULT DAY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:M CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-730-0060
Mailing Address - Street 1:107 N REED ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6825
Mailing Address - Country:US
Mailing Address - Phone:815-730-0060
Mailing Address - Fax:815-741-0943
Practice Address - Street 1:107 N REED ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6825
Practice Address - Country:US
Practice Address - Phone:815-730-0060
Practice Address - Fax:815-741-0943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0600X
ILADS1102001347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No347C00000XTransportation ServicesPrivate Vehicle