Healthcare Provider Details

I. General information

NPI: 1790035087
Provider Name (Legal Business Name): CARMELITE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9401 APHRODITE DR.
ANCHORAGE AK
99515
US

IV. Provider business mailing address

9401 APHRODITE DR.
ANCHORAGE AK
99515
US

V. Phone/Fax

Practice location:
  • Phone: 907-336-1296
  • Fax: 907-336-1298
Mailing address:
  • Phone: 907-336-1296
  • Fax: 907-336-1298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number100955
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierRLX
Identifier TypeOTHER
Identifier StateAK
Identifier IssuerHOME AND COMMUNITY BASED WAIVER PROGRAM

VIII. Authorized Official

Name: AINA R FOWLER
Title or Position: ADMINISTRATOR/OWNER
Credential:
Phone: 907-336-1296