MEDICARE: BRENTWOOD ASSISTED LIVING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3104A0625X	Assisted Living Facility (Mental Illness)

General Provider Information

NPI Number	:	1043050339
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENTWOOD ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	3408 N STAR ST
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99503-4539
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3408 N STAR ST
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99503-4539
Country	:	US
Telephone Number	:	909-750-0292
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MALIAS LAKE ANDREWS
Credential	:
Telephone Number	:	909-750-0292

Provider Enumeration Date	:	05/25/2024
Last Update Date	:	05/25/2024

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