MEDICARE: SERENE GRACE ASSISTED LIVING HOME

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	310400000X	Assisted Living Facility	101074	AK

General Provider Information

NPI Number	:	1790177764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENE GRACE ASSISTED LIVING HOME

Provider Business Mailing Address
First Line	:	3639 E 74TH AVE
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99507-2829
Country	:	US
Telephone Number	:	907-272-4073
Fax Number	:	907-552-1626

Provider Business Practice Location Address
First Line	:	3639 E 74TH AVE
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99507-2829
Country	:	US
Telephone Number	:	907-272-4073
Fax Number	:	907-552-1626

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. MIRASOL CARIAGA WILLIAMS
Credential	:
Telephone Number	:	907-244-1765

Provider Enumeration Date	:	02/26/2015
Last Update Date	:	02/26/2015

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