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General NPI Number Information
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NPI Number | 1407293145
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Entity Type | Organization
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Legal Business Name | OUR HOUSE ON THE LAKE LLC
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Dates
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Enumeration Date | 06/03/2013
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Last Update Date | 06/03/2013
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Provider Practice Location Address
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Address Line | 47710 INTERLAKE DR
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City | KENAI
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State | AK
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Zip | 99611-9694
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Country | US
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Telephone | 907-776-8684
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Fax |
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Provider Business Mailing Address
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Address Line | 47710 INTERLAKE DR
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City | KENAI
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State | AK
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Zip | 99611-9694
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Country | US
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Telephone | 907-776-8684
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | BONITA R QUALE
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Credential |
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Telephone | 907-776-8684
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 100608
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License Number State | AK
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Taxonomy #2
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 224
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License Number State | AK
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