Provider Demographics
NPI:1902936420
Name:AUTUMN LEAVES, INC.
Entity type:Organization
Organization Name:AUTUMN LEAVES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JACOBUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-763-2191
Mailing Address - Street 1:1479 S 44TH ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-4323
Mailing Address - Country:US
Mailing Address - Phone:217-422-2773
Mailing Address - Fax:
Practice Address - Street 1:1479 S 44TH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-4323
Practice Address - Country:US
Practice Address - Phone:217-422-2773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AUTUMN LEAVES. INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-06
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38737315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities