MEDICARE: ALASKA TREE HOUSE 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	3104A0625X	Assisted Living Facility (Mental Illness)	100985	AK
2	3104A0630X	Assisted Living Facility (Behavioral Disturbances)	100985	AK
3	310400000X	Assisted Living Facility	100985	AK

General Provider Information

NPI Number	:	1730424383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALASKA TREE HOUSE LLC

Provider Business Mailing Address
First Line	:	1021 TURPIN ST APT 3
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99504-1772
Country	:	US
Telephone Number	:	907-258-8733
Fax Number	:	907-336-8272

Provider Business Practice Location Address
First Line	:	1021 TURPIN ST APT 2
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99504-1772
Country	:	US
Telephone Number	:	907-258-8733
Fax Number	:	907-336-8272

Authorized Official
Title or Position	:	MEMBER
Name	:	MS. ADELE TARA DAVIS
Credential	:
Telephone Number	:	907-258-8733

Provider Enumeration Date	:	12/09/2012
Last Update Date	:	12/09/2012

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Directions to “ALASKA TREE HOUSE LLC ” Practice Location

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