Provider Demographics
NPI:1164788071
Name:TRANQUILITY MANOR ESTATES
Entity Type:Organization
Organization Name:TRANQUILITY MANOR ESTATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:KORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-746-4220
Mailing Address - Street 1:1205 N TRANQUILITY LN
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-8624
Mailing Address - Country:US
Mailing Address - Phone:907-746-4220
Mailing Address - Fax:
Practice Address - Street 1:1950 HEMMER ROAD
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645
Practice Address - Country:US
Practice Address - Phone:907-745-2012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRANQUILITY MANOR LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100954310400000X
AK100719310400000X
AK267310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL4070Medicaid
AKRL4310Medicaid