Provider Demographics
NPI:1417126608
Name:GUIDING LIGHT ASSISTANT LIVING HOME
Entity Type:Organization
Organization Name:GUIDING LIGHT ASSISTANT LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:907-227-6892
Mailing Address - Street 1:11522 AURORA ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7846
Mailing Address - Country:US
Mailing Address - Phone:907-227-6892
Mailing Address - Fax:907-726-2902
Practice Address - Street 1:11522 AURORA ST
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7846
Practice Address - Country:US
Practice Address - Phone:907-227-6892
Practice Address - Fax:907-726-2902
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUIDING LIGHT ASSISTANT LIVING HOME LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-21
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100652310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCMG 176Medicaid