Provider Demographics
NPI:1073635280
Name:STONE BROOK INN INC
Entity Type:Organization
Organization Name:STONE BROOK INN INC
Other - Org Name:STONE BROOK INN 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT-ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AUDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-252-2679
Mailing Address - Street 1:PO BOX 144
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-0144
Mailing Address - Country:US
Mailing Address - Phone:907-260-4498
Mailing Address - Fax:907-262-1593
Practice Address - Street 1:48420 MOOSE RUN ROAD
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669
Practice Address - Country:US
Practice Address - Phone:907-260-4498
Practice Address - Fax:907-262-1593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL54122Medicaid