Provider Demographics
NPI:1891824892
Name:AUTUMN LEAVES, INC.
Entity Type:Organization
Organization Name:AUTUMN LEAVES, INC.
Other - Org Name:HICKORY STREET PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JACOBUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-763-2191
Mailing Address - Street 1:2576 N GREENWAY RD
Mailing Address - Street 2:
Mailing Address - City:CERRO GORDO
Mailing Address - State:IL
Mailing Address - Zip Code:61818-3022
Mailing Address - Country:US
Mailing Address - Phone:217-763-2191
Mailing Address - Fax:217-763-2101
Practice Address - Street 1:3905 E. HICKORY ST.
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521
Practice Address - Country:US
Practice Address - Phone:217-429-8231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AUTUMN LEAVES. INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-05
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL37846315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities