Healthcare Provider Details

I. General information

NPI: 1063259687
Provider Name (Legal Business Name): KODIAK ISLAND ASSISTED LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 07/11/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 SIMEONOF ST
KODIAK AK
99615-6517
US

IV. Provider business mailing address

914 THORSHEIM ST
KODIAK AK
99615-6165
US

V. Phone/Fax

Practice location:
  • Phone: 915-841-1117
  • Fax:
Mailing address:
  • Phone: 915-841-1117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MARY JEAN V SILVA
Title or Position: ADMINSTRATOR
Credential: PHD
Phone: 915-841-1117