Provider Demographics
NPI:1033258280
Name:KALIEDOSCOPE ASSISTED LIVING HOME
Entity Type:Organization
Organization Name:KALIEDOSCOPE ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CUPP
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:907-486-8186
Mailing Address - Street 1:PO BOX 3923
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-3923
Mailing Address - Country:US
Mailing Address - Phone:907-486-8186
Mailing Address - Fax:907-486-6260
Practice Address - Street 1:1331 MISSION RD
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6583
Practice Address - Country:US
Practice Address - Phone:907-486-8186
Practice Address - Fax:907-486-6260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100372310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility