Basic Information
| Provider Information | |||||||||
| NPI: | 1922097476 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUTUMN HEALTH CARE OF NEWARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 FORRY STREET | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403498175 | ||||||||
| FaxNumber: | 7403459289 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 FORRY STREET | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403498175 | ||||||||
| FaxNumber: | 7403459289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 01/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | HITCHENS | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7403459199 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 5545 | OH | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | 2555R | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2053594 | 05 | OH | MEDICAID |