Healthcare Provider Details

I. General information

NPI: 1023134178
Provider Name (Legal Business Name): MAIN STREET ASSISTED LIVING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4136 MAIN ST
HOMER AK
99603-7035
US

IV. Provider business mailing address

4136 MAIN ST
HOMER AK
99603-7035
US

V. Phone/Fax

Practice location:
  • Phone: 907-235-6149
  • Fax: 907-235-6149
Mailing address:
  • Phone: 907-235-6149
  • Fax: 907-235-6149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number00242
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number00242
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number00242
License Number StateAK

VIII. Authorized Official

Name: RUTH E BABCOCK
Title or Position: ADMINISTRATOR
Credential:
Phone: 907-235-6149