Provider Demographics
NPI:1497945067
Name:MAKUPA ASSISTED LIVING HOME
Entity Type:Organization
Organization Name:MAKUPA ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:IDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:POEPPING
Authorized Official - Suffix:
Authorized Official - Credentials:TMA/CNA
Authorized Official - Phone:907-441-7219
Mailing Address - Street 1:PO BOX 222556
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99522-2556
Mailing Address - Country:US
Mailing Address - Phone:907-441-7219
Mailing Address - Fax:907-344-2711
Practice Address - Street 1:8733 RUNAMARK PLACE
Practice Address - Street 2:B
Practice Address - City:ANCHIRAGE
Practice Address - State:AK
Practice Address - Zip Code:99502
Practice Address - Country:US
Practice Address - Phone:907-441-7219
Practice Address - Fax:907-344-2711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1005573104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1Medicaid