Healthcare Provider Details

I. General information

NPI: 1528746153
Provider Name (Legal Business Name): BIG LAKE COUNTRY CLUB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 07/05/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12528 W. HAWK LANE
HOUSTON AK
99694
US

IV. Provider business mailing address

PO BOX 520069
BIG LAKE AK
99652-0069
US

V. Phone/Fax

Practice location:
  • Phone: 907-232-8466
  • Fax:
Mailing address:
  • Phone: 907-232-8466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN PHILLIP GEDDES
Title or Position: MANAGER
Credential:
Phone: 907-250-6605