Healthcare Provider Details

I. General information

NPI: 1679603740
Provider Name (Legal Business Name): MAT-SU ACTIVITY AND RESPITE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 02/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 E BOGARD RD
WASILLA AK
99654-7113
US

IV. Provider business mailing address

951 E BOGARD RD
WASILLA AK
99654-7113
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-8622
  • Fax: 907-357-8624
Mailing address:
  • Phone: 907-357-8622
  • Fax: 907-357-8624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: LAURA SASSEEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 907-357-8622