Provider Demographics
NPI:1548431893
Name:AUTUMN CORPORATION
Entity Type:Organization
Organization Name:AUTUMN CORPORATION
Other - Org Name:AUTUMN CARE OF MOCKSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:252-443-6265
Mailing Address - Street 1:1007 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-2548
Mailing Address - Country:US
Mailing Address - Phone:336-751-3535
Mailing Address - Fax:336-751-0028
Practice Address - Street 1:1007 HOWARD ST
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2548
Practice Address - Country:US
Practice Address - Phone:336-751-3535
Practice Address - Fax:336-751-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0221313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406212Medicaid