1790002459 NPI number — COLONY MANOR AT VILLAGE PARK ASSISTED LIVING HOME

Table of content: (NPI 1790002459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790002459 NPI number — COLONY MANOR AT VILLAGE PARK ASSISTED LIVING HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLONY MANOR AT VILLAGE PARK ASSISTED LIVING HOME
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:
1790002459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 870469
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASILLA
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-373-1880
Provider Business Mailing Address Fax Number:
907-373-1820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2051 PORCUPINE TR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASILLA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-373-1880
Provider Business Practice Location Address Fax Number:
907-373-1820
Provider Enumeration Date:
04/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DAHL
Authorized Official First Name:
NATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
907-373-1880

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  100649 , 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: RL97972 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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