MEDICARE: ONE FAMILY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QB0400X	Birthing Clinic/Center	ONF02030000001	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ONF02030000001	OTHER	AK	STATE LICENSE FACILTY ID

General Provider Information

NPI Number	:	1164697504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONE FAMILY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 112381
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99511-2381
Country	:	US
Telephone Number	:	907-349-3054
Fax Number	:	907-349-3056

Provider Business Practice Location Address
First Line	:	1108 E NORTHERN LIGHTS BLVD
Second Line	:	STE C
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-4219
Country	:	US
Telephone Number	:	907-349-3054
Fax Number	:	907-349-3056

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. SHAUNA B TIESZEN
Credential	:
Telephone Number	:	907-250-1944

Provider Enumeration Date	:	04/27/2008
Last Update Date	:	04/27/2008

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