Provider Demographics
NPI:1043927700
Name:AGUSTIN, ROLAND I
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:I
Last Name:AGUSTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11621 NIX CT
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-3409
Mailing Address - Country:US
Mailing Address - Phone:248-250-3800
Mailing Address - Fax:907-868-2958
Practice Address - Street 1:11621 NIX CT
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-3409
Practice Address - Country:US
Practice Address - Phone:248-250-3800
Practice Address - Fax:907-868-2958
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2154560310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility