Provider Demographics
NPI:1407056716
Name:AUTUMN YEARS CARE CENTER
Entity Type:Organization
Organization Name:AUTUMN YEARS CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTBROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-899-5306
Mailing Address - Street 1:217 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-5514
Mailing Address - Country:US
Mailing Address - Phone:480-899-5306
Mailing Address - Fax:480-855-5193
Practice Address - Street 1:217 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-5514
Practice Address - Country:US
Practice Address - Phone:480-899-5306
Practice Address - Fax:480-855-5193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALC4889310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ975253Medicaid