Provider Demographics
NPI:1255867263
Name:MONTANA CREEK ASSISTED LIVING HOME
Entity Type:Organization
Organization Name:MONTANA CREEK ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLUSKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-354-3441
Mailing Address - Street 1:PO BOX 735
Mailing Address - Street 2:
Mailing Address - City:WILLOW
Mailing Address - State:AK
Mailing Address - Zip Code:99688-0735
Mailing Address - Country:US
Mailing Address - Phone:907-354-3441
Mailing Address - Fax:
Practice Address - Street 1:19205 E FUTURE RD
Practice Address - Street 2:
Practice Address - City:TALKEETNA
Practice Address - State:AK
Practice Address - Zip Code:99676
Practice Address - Country:US
Practice Address - Phone:907-354-3441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100437320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities