MEDICARE: FRIENDLY EMPIRE 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	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1568046183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRIENDLY EMPIRE ASSISTED LIVING HOME, LLC

Provider Business Mailing Address
First Line	:	2721 W 69TH AVE
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99502-2240
Country	:	US
Telephone Number	:	907-229-9522
Fax Number	:

Provider Business Practice Location Address
First Line	:	2721 W 69TH AVE
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99502-2240
Country	:	US
Telephone Number	:	907-229-9522
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	FUSI HOLA
Credential	:
Telephone Number	:	907-229-9522

Provider Enumeration Date	:	05/10/2021
Last Update Date	:	05/10/2021

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