=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265717540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AURORA BOREALIS ASSISTED LIVING HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2011
-----------------------------------------------------
Last Update Date | 10/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22179 NORTH BIRCHWOOD LOOP
-----------------------------------------------------
City | CHUGIAK
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-688-2283
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 670030
-----------------------------------------------------
City | CHUGIAK
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99567-0030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-688-2283
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. POMPOSA LUCAS PORTERFIELD
-----------------------------------------------------
Credential | CNA
-----------------------------------------------------
Telephone | 907-688-2283
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 939279
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------