Healthcare Provider Details

I. General information

NPI: 1902518848
Provider Name (Legal Business Name): BANYAN ALASKA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2022
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 E BEGICH CIRCLE
WASILLA AK
99654
US

IV. Provider business mailing address

225 N FEDERAL HWY
POMPANO BEACH FL
33062-4319
US

V. Phone/Fax

Practice location:
  • Phone: 907-290-5450
  • Fax: 907-290-5460
Mailing address:
  • Phone: 954-533-7705
  • Fax: 954-781-7173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: ANASTASIA NICHOLE NAUMAN
Title or Position: CONTRACTING AND CRED MANAGER
Credential:
Phone: 410-800-8861