Healthcare Provider Details

I. General information

NPI: 1154626141
Provider Name (Legal Business Name): AMERICAN DREAM CONSTRUCTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2011
Last Update Date: 01/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3381 E GODFREY DR
WASILLA AK
99654-0320
US

IV. Provider business mailing address

3381 E GODFREY DR
WASILLA AK
99654-0320
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-8640
  • Fax: 907-357-8630
Mailing address:
  • Phone: 907-357-8640
  • Fax: 907-357-8630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number34356
License Number StateAK

VII. Legacy identifiers

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

# 1
IdentifierEM9194
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: TAMMY LYNN BRAMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 907-357-8640