Provider Demographics
NPI:1356402515
Name:AUTUMN LEAVES NURSING AND REHAB INC
Entity type:Organization
Organization Name:AUTUMN LEAVES NURSING AND REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:IRWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-657-8969
Mailing Address - Street 1:321 KILGORE DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75652-5215
Mailing Address - Country:US
Mailing Address - Phone:903-657-1923
Mailing Address - Fax:903-657-6764
Practice Address - Street 1:321 KILGORE DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-5215
Practice Address - Country:US
Practice Address - Phone:903-657-1923
Practice Address - Fax:903-657-6464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116372314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000449901Medicaid
TX000449901Medicaid