MEDICARE: MALUPO'S HAVEN 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	3104A0630X	Assisted Living Facility (Behavioral Disturbances)	101135	AK

General Provider Information

NPI Number	:	1417304528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALUPO'S HAVEN ASSISTED LIVING HOME LLC

Provider Business Mailing Address
First Line	:	7221 KISKA CIR
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99504-3408
Country	:	US
Telephone Number	:	907-222-0389
Fax Number	:	907-222-0736

Provider Business Practice Location Address
First Line	:	7221 KISKA CIR
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99504-3408
Country	:	US
Telephone Number	:	907-222-0389
Fax Number	:	907-222-0736

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	SHANTEL MAY BUNTING
Credential	:
Telephone Number	:	907-602-8464

Provider Enumeration Date	:	05/18/2016
Last Update Date	:	05/18/2016

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