Provider Demographics
NPI:1477798825
Name:THE ALASKA SHIELD AGENCY
Entity Type:Organization
Organization Name:THE ALASKA SHIELD AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-258-5665
Mailing Address - Street 1:HC 35 BOX 5475A
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8801
Mailing Address - Country:US
Mailing Address - Phone:907-258-5665
Mailing Address - Fax:
Practice Address - Street 1:11487 NIKOLAI CIRCLE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8801
Practice Address - Country:US
Practice Address - Phone:907-258-5665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK723449251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCMG678OtherDIVISION OF SENIOR AND DISABLED SERVICES