Provider Demographics
NPI:1003032327
Name:AVELINA ASSISTED LIVING HOME
Entity Type:Organization
Organization Name:AVELINA ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-333-6649
Mailing Address - Street 1:285 FLOWER ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-2140
Mailing Address - Country:US
Mailing Address - Phone:907-333-6649
Mailing Address - Fax:907-375-0950
Practice Address - Street 1:242 PARK ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2249
Practice Address - Country:US
Practice Address - Phone:907-333-6649
Practice Address - Fax:907-375-0950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK000265310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL8772OtherMCI