Healthcare Provider Details

I. General information

NPI: 1326364647
Provider Name (Legal Business Name): EAGLE CREST ALH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 02/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22626 CHAMBER LN
CHUGIAK AK
99567-6155
US

IV. Provider business mailing address

22306 SHADOWY SPRUCE DR
CHUGIAK AK
99567-5452
US

V. Phone/Fax

Practice location:
  • Phone: 907-688-0123
  • Fax: 907-688-0123
Mailing address:
  • Phone: 907-688-0123
  • Fax: 907-688-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number959821
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number959821
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number959821
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number959821
License Number StateAK
# 5
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number959821
License Number StateAK

VIII. Authorized Official

Name: MRS. BELINDA BALDWIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 907-688-0123