Basic Information
| Provider Information | |||||||||
| NPI: | 1063491058 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUTUMN HILLS CARE CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2565 NILES VIENNA RD | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444464401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306522053 | ||||||||
| FaxNumber: | 3306520112 | ||||||||
| Practice Location | |||||||||
| Address1: | 2565 NILES VIENNA RD | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444464401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306522053 | ||||||||
| FaxNumber: | 3306520112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DIPASQUA | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3306522053 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3679 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0619272 | 05 | OH | MEDICAID |