1932379351 NPI number — GRACEFUL LIVING LLC

Table of content: (NPI 1932379351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932379351 NPI number — GRACEFUL LIVING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACEFUL LIVING 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:
1932379351
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6300 E 9TH AVE
Provider Second Line Business Mailing Address:
1100 FRIENDLY LANE
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99504-1720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-338-3135
Provider Business Mailing Address Fax Number:
907-338-3012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 FRIENDLY LN
Provider Second Line Business Practice Location Address:
6600 EAST 11TH AVE
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99504-2024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-338-0444
Provider Business Practice Location Address Fax Number:
907-338-5768
Provider Enumeration Date:
03/03/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ULOFOSHIO
Authorized Official First Name:
CHRISTIANA
Authorized Official Middle Name:
ILOSEN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
907-338-3135

Provider Taxonomy Codes

  • Taxonomy code: 343900000X , with the licence number:  34390000X , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 344600000X , with the licence number: 3446OOOOX TAXI , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385H00000X , with the licence number: 385HR0000X , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385HR2060X , with the licence number: 385HR2060 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1548461445 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: HC3704 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".