Healthcare Provider Details

I. General information

NPI: 1700143211
Provider Name (Legal Business Name): SHANGRI'LA RANCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

782 ADVENTURE RD
FAIRBANKS AK
99712-3330
US

IV. Provider business mailing address

PO BOX 56776
NORTH POLE AK
99705-1776
US

V. Phone/Fax

Practice location:
  • Phone: 907-687-7775
  • Fax:
Mailing address:
  • Phone: 907-687-7775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateAK

VIII. Authorized Official

Name: KARMA SPARKS BROWN
Title or Position: OWNER/OPERATOR
Credential:
Phone: 907-687-7775