Provider Demographics
NPI:1669236626
Name:AUTUMN BLISS HOME LLC
Entity type:Organization
Organization Name:AUTUMN BLISS HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:REGINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-373-7619
Mailing Address - Street 1:17885 ATHOL ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-5127
Mailing Address - Country:US
Mailing Address - Phone:626-373-7619
Mailing Address - Fax:
Practice Address - Street 1:17885 ATHOL ST
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-5127
Practice Address - Country:US
Practice Address - Phone:626-373-7619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility