Provider Demographics
NPI:1659623536
Name:AUTUMN HILLS OF BEMIDJI, INC.
Entity Type:Organization
Organization Name:AUTUMN HILLS OF BEMIDJI, INC.
Other - Org Name:AUTUMN HILLS HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:CLOOSE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:218-333-3854
Mailing Address - Street 1:2528 PARK AVE NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-2432
Mailing Address - Country:US
Mailing Address - Phone:218-333-3854
Mailing Address - Fax:218-333-3855
Practice Address - Street 1:2528 PARK AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-2432
Practice Address - Country:US
Practice Address - Phone:218-333-3854
Practice Address - Fax:218-333-3855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN358062251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA034943700OtherUMPI