Provider Demographics
NPI:1407293145
Name:OUR HOUSE ON THE LAKE LLC
Entity Type:Organization
Organization Name:OUR HOUSE ON THE LAKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BONITA
Authorized Official - Middle Name:R
Authorized Official - Last Name:QUALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-776-8684
Mailing Address - Street 1:47710 INTERLAKE DR
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-9694
Mailing Address - Country:US
Mailing Address - Phone:907-776-8684
Mailing Address - Fax:
Practice Address - Street 1:47710 INTERLAKE DR
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-9694
Practice Address - Country:US
Practice Address - Phone:907-776-8684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK224310400000X
AK100608310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL4771Medicaid
AKRL3719Medicaid