Provider Demographics
NPI:1992841746
Name:AUTUMN LEAVES ASSISTED LIVING CARE INC
Entity Type:Organization
Organization Name:AUTUMN LEAVES ASSISTED LIVING CARE INC
Other - Org Name:AUTUMN LEAVES ASSISTED LIVING INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WILMA
Authorized Official - Middle Name:JULIA
Authorized Official - Last Name:LA CROIX
Authorized Official - Suffix:
Authorized Official - Credentials:RN ALPCM
Authorized Official - Phone:210-256-0553
Mailing Address - Street 1:9202 NEW GUILBEAU RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78250-5802
Mailing Address - Country:US
Mailing Address - Phone:210-844-7927
Mailing Address - Fax:210-463-9374
Practice Address - Street 1:6411 RIDGE PLACE ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78250-4038
Practice Address - Country:US
Practice Address - Phone:210-256-0553
Practice Address - Fax:210-680-1343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX030361311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1992841746Medicaid