Healthcare Provider Details

I. General information

NPI: 1730424383
Provider Name (Legal Business Name): ALASKA TREE HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2012
Last Update Date: 12/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 TURPIN ST APT 2
ANCHORAGE AK
99504-1772
US

IV. Provider business mailing address

1021 TURPIN ST APT 3
ANCHORAGE AK
99504-1772
US

V. Phone/Fax

Practice location:
  • Phone: 907-258-8733
  • Fax: 907-336-8272
Mailing address:
  • Phone: 907-258-8733
  • Fax: 907-336-8272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number100985
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number100985
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number100985
License Number StateAK

VIII. Authorized Official

Name: MS. ADELE TARA DAVIS
Title or Position: MEMBER
Credential:
Phone: 907-258-8733