NPIMap

Organization Active NPI

Autumn Leaves, Inc.

Doing business as Hickory Street Place

  • Intellectual Disabilities Intermediate Care Facility
  • Decatur, IL
National Provider Identifier
1891824892
Registry record updated Jan 23, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
37846 Issued in IL
Legal business name
AUTUMN LEAVES, INC.
Doing business as
Hickory Street Place
Practice address
3905 E. Hickory St.
Decatur, IL 62521
Phone
(217) 429-8231
NPI assigned
Mar 5, 2007
Last updated
Jan 23, 2017By the provider in NPPES
Organization subpart
Yes
Parent organization
AUTUMN LEAVES. INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 23, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. David Michael Jacobus
Title
President
Phone
(217) 763-2191

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 37846 IL Primary

Addresses

Primary practice location

3905 E. Hickory St.
Decatur, IL 62521

Mailing address

2576 N Greenway Rd
Cerro Gordo, IL 61818-3022
Phone (217) 763-2191

Other names 1

  • HICKORY STREET PLACE Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Autumn Leaves Inc3 organizations share this tax ID, including this one
Part of
Autumn Leaves Inc

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173052800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1485129600000",
    "number": "1891824892",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2576 N GREENWAY RD",
            "city": "CERRO GORDO",
            "state": "IL",
            "postal_code": "618183022",
            "telephone_number": "217-763-2191",
            "fax_number": "217-763-2101"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3905 E. HICKORY ST.",
            "city": "DECATUR",
            "state": "IL",
            "postal_code": "62521",
            "telephone_number": "217-429-8231"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AUTUMN LEAVES, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "AUTUMN LEAVES. INC",
        "enumeration_date": "2007-03-05",
        "last_updated": "2017-01-23",
        "status": "A",
        "authorized_official_last_name": "JACOBUS",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "MICHAEL",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "217-763-2191",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "IL",
            "license": "37846",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "HICKORY STREET PLACE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Decatur, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 23, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.