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General NPI Number Information
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NPI Number | 1477403509
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Entity Type | Organization
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Legal Business Name | QUEEN ANNE AVENUE LLC
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Dates
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Enumeration Date | 01/29/2026
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Last Update Date | 01/29/2026
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Provider Practice Location Address
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Address Line | 6816 W QUEEN ANNE AVE HOUSE #1
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City | WASILLA
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State | AK
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Zip | 99654
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Country | US
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Telephone | 907-318-2180
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Fax | 866-336-7276
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Provider Business Mailing Address
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Address Line | 1741 E ROSEVILLE PKWY STE 100
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City | ROSEVILLE
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State | CA
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Zip | 95661-6450
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Country | US
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Telephone | 916-784-1149
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Fax | 866-336-7276
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Authorized Official
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Title or Position | CEO
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Name | MR. ROSS MORTON
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Credential | JD
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Telephone | 916-847-4006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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