Provider Demographics
NPI:1114140456
Name:SUE'S SOURDOUGH ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:SUE'S SOURDOUGH ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CRESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-345-1854
Mailing Address - Street 1:PO BOX 110041
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99511-0041
Mailing Address - Country:US
Mailing Address - Phone:907-345-1854
Mailing Address - Fax:
Practice Address - Street 1:14650 PARK HILLS DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99516-4241
Practice Address - Country:US
Practice Address - Phone:907-345-1854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100415310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL3740Medicaid