Provider Demographics
NPI:1508029240
Name:ARK OF EMMANUEL ASSISTING LIVING HOME
Entity Type:Organization
Organization Name:ARK OF EMMANUEL ASSISTING LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMNISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:B
Authorized Official - Last Name:PENTECOSTES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:907-677-9289
Mailing Address - Street 1:5454 EMMANUEL AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4934
Mailing Address - Country:US
Mailing Address - Phone:907-677-9289
Mailing Address - Fax:907-677-9289
Practice Address - Street 1:5454 EMMANUEL AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4934
Practice Address - Country:US
Practice Address - Phone:907-677-9289
Practice Address - Fax:907-677-9289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK908797310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility