Healthcare Provider Details

I. General information

NPI: 1659009272
Provider Name (Legal Business Name): FAIRBANKS ASSISTED LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 SYRACUSE CT APT 1
FAIRBANKS AK
99709-2977
US

IV. Provider business mailing address

114 CAHABA ST
ENTERPRISE AL
36330-3627
US

V. Phone/Fax

Practice location:
  • Phone: 907-987-0304
  • Fax:
Mailing address:
  • Phone: 907-888-5163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DIANA MARGALEEN MHURIRO
Title or Position: OWNER
Credential: RN
Phone: 907-888-5163