Provider Demographics
NPI:1255856639
Name:SAYAVONG, DEMILYN
Entity Type:Individual
Prefix:
First Name:DEMILYN
Middle Name:
Last Name:SAYAVONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11245 VIA BALBOA
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-2910
Mailing Address - Country:US
Mailing Address - Phone:1907-231-7296
Mailing Address - Fax:907-336-7296
Practice Address - Street 1:11245 VIA BALBOA
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-2910
Practice Address - Country:US
Practice Address - Phone:1907-231-7296
Practice Address - Fax:907-336-7296
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101195310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK048Medicaid