=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184436883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALASKA LIFE GROUP HOME, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2025
-----------------------------------------------------
Last Update Date | 01/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23812 DOLLY AVE
-----------------------------------------------------
City | CHUGIAK
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99567-5577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-854-0443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 670590
-----------------------------------------------------
City | CHUGIAK
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99567-0590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | HOLLY CANNON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 907-854-0443
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------