Provider Demographics
NPI:1518345214
Name:AUTUMN LAKE LLC
Entity Type:Organization
Organization Name:AUTUMN LAKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CRISTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-246-2740
Mailing Address - Street 1:11758 S HARRELLS FERRY RD STE C
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-2365
Mailing Address - Country:US
Mailing Address - Phone:225-246-2740
Mailing Address - Fax:225-367-4687
Practice Address - Street 1:11758 S HARRELLS FERRY RD STE C
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2365
Practice Address - Country:US
Practice Address - Phone:225-246-2740
Practice Address - Fax:225-367-4687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1729990Medicaid