MEDICARE: NORTHERN HOME HEALTH, 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1255635181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN HOME HEALTH, LLC

Provider Business Mailing Address
First Line	:	PO BOX 220813
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99522-0813
Country	:	US
Telephone Number	:	907-868-1919
Fax Number	:	907-245-6269

Provider Business Practice Location Address
First Line	:	4101 ARCTIC BLVD
Second Line	:	STE. 105
City	:	ANCHORAGE
State	:	AK
Zip	:	99503-5702
Country	:	US
Telephone Number	:	907-868-1919
Fax Number	:	907-245-6269

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MRS. SUZANNE C HICKEL
Credential	:	CSA
Telephone Number	:	907-868-1919

Provider Enumeration Date	:	01/06/2011
Last Update Date	:	01/06/2011

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