1356059125 NPI number — INNER LIGHT THERAPY LLC

Table of content: (NPI 1356059125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356059125 NPI number — INNER LIGHT THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNER LIGHT THERAPY 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:
1356059125
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1131 E 76TH AVE STE 201
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:
99518-3209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-205-7887
Provider Business Mailing Address Fax Number:
907-206-7203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1131 E 76TH AVE STE 201
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:
99518-3209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-205-7887
Provider Business Practice Location Address Fax Number:
907-206-7203
Provider Enumeration Date:
11/10/2022

Additional Information

Authorized Official

Authorized Official Last Name:
SIMMONS
Authorized Official First Name:
SHANNA
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
OWNER/CLINICAL MANAGER
Authorized Official Telephone Number:
907-205-7887

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 185850 . This is a "STATE OF ALASKA, PROFESSIONAL LICENSING DIVISION" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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