Provider Demographics
NPI:1720284839
Name:AUTUMN VIEW SENIOR DAY SERVICES, LLC
Entity Type:Organization
Organization Name:AUTUMN VIEW SENIOR DAY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KWANTRELL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-343-9013
Mailing Address - Street 1:14321 DEDEAUX RD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3369
Mailing Address - Country:US
Mailing Address - Phone:228-831-0048
Mailing Address - Fax:228-831-0058
Practice Address - Street 1:14321 DEDEAUX RD
Practice Address - Street 2:SUITE 14
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3369
Practice Address - Country:US
Practice Address - Phone:228-831-0048
Practice Address - Fax:228-831-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health
No251G00000XAgenciesHospice Care, Community BasedGroup - Multi-Specialty