Provider Demographics
NPI:1073704102
Name:OUR LADY OF FATIMA
Entity Type:Organization
Organization Name:OUR LADY OF FATIMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:GABAT
Authorized Official - Last Name:NIDOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-529-7495
Mailing Address - Street 1:4030 DEFIANCE ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-4368
Mailing Address - Country:US
Mailing Address - Phone:907-529-7495
Mailing Address - Fax:
Practice Address - Street 1:4030 DEFIANCE ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-4368
Practice Address - Country:US
Practice Address - Phone:907-529-7495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100559310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL7080Medicaid