Healthcare Provider Details

I. General information

NPI: 1215130372
Provider Name (Legal Business Name): ALASKA BRAIN CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4551 E BOGARD RD
WASILLA AK
99654-6075
US

IV. Provider business mailing address

4551 E BOGARD RD
WASILLA AK
99654-6075
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-6500
  • Fax: 888-456-0663
Mailing address:
  • Phone: 907-373-6500
  • Fax: 888-456-0663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number5128
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5128
License Number StateAK

VIII. Authorized Official

Name: MR. JEFFREY L SPONSLER
Title or Position: OWNER
Credential: M.D., M.S.
Phone: 907-376-6523