| NPI | 1679741805 |
|---|---|
| Other Name | AUTUMN LAKE |
| Entity Type | Organization |
| Authorized Contact | BENJAMIN STORTZ Chief Administrative Officer 815-741-7042 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Enumeration Date | 2008-02-11 |
| Last Update Date | 2008-06-12 |