Provider Demographics
NPI:1326496092
Name:SIMPLY BLUE,ALH,LLC
Entity Type:Organization
Organization Name:SIMPLY BLUE,ALH,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLANGCA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:203-822-1055
Mailing Address - Street 1:7451 TYONE CT
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-3531
Mailing Address - Country:US
Mailing Address - Phone:907-570-6699
Mailing Address - Fax:907-929-1178
Practice Address - Street 1:7451 TYONE CT
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-3531
Practice Address - Country:US
Practice Address - Phone:907-570-6699
Practice Address - Fax:907-929-1178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10029349310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRLXOtherDHSS, HOME AND BASE WAIVER PROGRAM PROVIDER CERTIFICATION