1225151533 NPI number — SUNSET HAVEN ALH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225151533 NPI number — SUNSET HAVEN ALH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNSET HAVEN ALH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225151533
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5950 KODY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99504-5307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-337-1190
Provider Business Mailing Address Fax Number:
907-337-1190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4210 GALACTICA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99517-1444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-243-1169
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OCAMPO
Authorized Official First Name:
ANGELO
Authorized Official Middle Name:
MEDINA
Authorized Official Title or Position:
DESIGNEE ADMINISTRATOR
Authorized Official Telephone Number:
907-243-1169

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  434082 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RL 6741 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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