=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992684385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHALOM ASSISTED LIVING HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2025
-----------------------------------------------------
Last Update Date | 08/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9950 W. TRANQUILITY DR.
-----------------------------------------------------
City | WASILLA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-232-7529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 298223
-----------------------------------------------------
City | WASILLA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99629-8223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-232-7529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. JACQUELINE LEEANN NOYES
-----------------------------------------------------
Credential | OWNER
-----------------------------------------------------
Telephone | 907-232-7529
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------