Provider Demographics
NPI:1083820153
Name:HEARTLAND CARE ASSISTED LIVING
Entity Type:Organization
Organization Name:HEARTLAND CARE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:CHESSER-WITMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-374-7738
Mailing Address - Street 1:1187 KODIAK ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4835
Mailing Address - Country:US
Mailing Address - Phone:907-374-7738
Mailing Address - Fax:907-374-7738
Practice Address - Street 1:704 WAVES RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3409
Practice Address - Country:US
Practice Address - Phone:907-374-7738
Practice Address - Fax:907-374-7738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK742338261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service