1861515173 NPI number — ASSIST ADULT CARE FACILITY, LLC

Table of content: (NPI 1861515173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861515173 NPI number — ASSIST ADULT CARE FACILITY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASSIST ADULT CARE FACILITY, LLC
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:
1861515173
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:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4830 LEAH CT
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:
99508-3787
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-770-3787
Provider Business Practice Location Address Fax Number:
907-337-1190
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:
907-230-1065

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  436467 , 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 67411 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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