Provider Demographics
NPI:1073765244
Name:ST MARY'S ASSISTED LIVING HOME #2
Entity Type:Organization
Organization Name:ST MARY'S ASSISTED LIVING HOME #2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:PARONE
Authorized Official - Last Name:GAUTHIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-349-0446
Mailing Address - Street 1:4001 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-2106
Mailing Address - Country:US
Mailing Address - Phone:907-929-1588
Mailing Address - Fax:
Practice Address - Street 1:4001 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2106
Practice Address - Country:US
Practice Address - Phone:907-929-1588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-18
Last Update Date:2008-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100566310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL56791Medicaid