Healthcare Provider Details

I. General information

NPI: 1699320127
Provider Name (Legal Business Name): WASILLA GROUP HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 W LYNN DR
WASILLA AK
99654-0949
US

IV. Provider business mailing address

3660 W LYNN DR
WASILLA AK
99654-0949
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-0102
  • Fax: 907-631-4253
Mailing address:
  • Phone: 907-357-0102
  • Fax: 907-631-4253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1026476
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: MS. RENNE CHAMPAGNE
Title or Position: OWNER ADMINISTRATOR
Credential: CNA
Phone: 907-357-0102