Healthcare Provider Details

I. General information

NPI: 1477798825
Provider Name (Legal Business Name): THE ALASKA SHIELD AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2008
Last Update Date: 12/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11487 NIKOLAI CIRCLE
WASILLA AK
99654-8801
US

IV. Provider business mailing address

HC 35 BOX 5475A
WASILLA AK
99654-8801
US

V. Phone/Fax

Practice location:
  • Phone: 907-258-5665
  • Fax:
Mailing address:
  • Phone: 907-258-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number723449
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierCMG678
Identifier TypeOTHER
Identifier StateAK
Identifier IssuerDIVISION OF SENIOR AND DISABLED SERVICES

VIII. Authorized Official

Name: MARTHA BRADLEY
Title or Position: OWNER
Credential:
Phone: 907-258-5665