Healthcare Provider Details

I. General information

NPI: 1033258280
Provider Name (Legal Business Name): KALIEDOSCOPE ASSISTED LIVING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 MISSION RD
KODIAK AK
99615-6583
US

IV. Provider business mailing address

PO BOX 3923
KODIAK AK
99615-3923
US

V. Phone/Fax

Practice location:
  • Phone: 907-486-8186
  • Fax: 907-486-6260
Mailing address:
  • Phone: 907-486-8186
  • Fax: 907-486-6260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number100372
License Number StateAK

VIII. Authorized Official

Name: MS. TERRA L CUPP
Title or Position: ADMINISTRATOR
Credential: CNA
Phone: 907-486-8186