Provider Demographics
NPI:1740603968
Name:AUTUMN WOOD INC
Entity Type:Organization
Organization Name:AUTUMN WOOD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNADINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-974-5120
Mailing Address - Street 1:15988 CRYSTAL DOWNS E
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-8481
Mailing Address - Country:US
Mailing Address - Phone:313-974-5120
Mailing Address - Fax:
Practice Address - Street 1:15988 CRYSTAL DOWNS E
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-8481
Practice Address - Country:US
Practice Address - Phone:313-974-5120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility