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General NPI Number Information
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NPI Number | 1609106251
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Entity Type | Organization
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Legal Business Name | GRANNY'S LOG CABIN CARE CENTER
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Dates
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Enumeration Date | 01/04/2010
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Last Update Date | 01/04/2010
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Provider Practice Location Address
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Address Line | 3041 N CAMBAY CT
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City | WASILLA
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State | AK
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Zip | 99654-1271
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Country | US
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Telephone | 907-631-3261
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Fax | 907-357-5813
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Provider Business Mailing Address
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Address Line | 647 N TIFFANY DR
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City | PALMER
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State | AK
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Zip | 99645-8410
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Country | US
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Telephone | 907-357-8800
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Fax | 907-357-5813
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Authorized Official
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Title or Position | OWNER
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Name | MS. SHERRY ANN BUTTERS
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Credential |
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Telephone | 907-357-8800
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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 | 100785
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License Number State | AK
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