Healthcare Provider Details

I. General information

NPI: 1487294310
Provider Name (Legal Business Name): FORGET ME NOT CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2020
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 W AMANDA DR
WASILLA AK
99623-1046
US

IV. Provider business mailing address

PO BOX 871282
WASILLA AK
99687-1282
US

V. Phone/Fax

Practice location:
  • Phone: 208-713-4603
  • Fax:
Mailing address:
  • Phone: 208-713-4603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
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: MARY A MILLER
Title or Position: ADMINISTRATOR
Credential:
Phone: 208-713-4603