MEDICARE: BIG LAKE COUNTRY CLUB

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	100554	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154580835
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIG LAKE COUNTRY CLUB

Provider Business Mailing Address
First Line	:	PO BOX 299136
Second Line	:
City	:	WASILLA
State	:	AK
Zip	:	99629-9136
Country	:	US
Telephone Number	:	907-892-6944
Fax Number	:

Provider Business Practice Location Address
First Line	:	12528 HAWK LANE
Second Line	:
City	:	HOUSTON
State	:	AK
Zip	:	99694-2528
Country	:	US
Telephone Number	:	907-892-6944
Fax Number	:

Authorized Official
Title or Position	:	STAFF OFFICE
Name	:	JESS G ADAMS
Credential	:
Telephone Number	:	907-892-6944

Provider Enumeration Date	:	06/06/2008
Last Update Date	:	07/22/2009

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Directions to “BIG LAKE COUNTRY CLUB ” Practice Location

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