MEDICARE: JEWEL LAKE ASSISTED LIVING HOME 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	310400000X	Assisted Living Facility	101014	AK

General Provider Information

NPI Number	:	1255761987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEWEL LAKE ASSISTED LIVING HOME LLC

Provider Business Mailing Address
First Line	:	4132 WEST 88TH AVE.
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99502
Country	:	US
Telephone Number	:	907-243-9570
Fax Number	:	907-245-0035

Provider Business Practice Location Address
First Line	:	4132 W 88TH AVE
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99502-5107
Country	:	US
Telephone Number	:	907-243-9570
Fax Number	:	907-245-0035

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. ARTHUR REYES BONGLO
Credential	:	REGISTERED NURSE
Telephone Number	:	907-243-9570

Provider Enumeration Date	:	11/15/2013
Last Update Date	:	11/15/2013

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