MEDICARE: BIG LAKE COUNTRY CLUB, 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	251B00000X	Case Management Agency	CMG	AK
2	251S00000X	Community/Behavioral Health Agency	HCS	AK
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	940288	AK

General Provider Information

NPI Number	:	1639497415
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIG LAKE COUNTRY CLUB, LLC

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

Authorized Official
Title or Position	:	PRESIDENT / ADMINISTRATOR
Name	:	MS. LYNDA PLETTNER
Credential	:
Telephone Number	:	907-892-6944

Provider Enumeration Date	:	05/04/2010
Last Update Date	:	07/05/2023

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Directions to “BIG LAKE COUNTRY CLUB, LLC ” Practice Location

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