Provider Demographics
NPI:1508616236
Name:ALASKAN AMAZING GRACE ALH LLC
Entity Type:Organization
Organization Name:ALASKAN AMAZING GRACE ALH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:FONSECA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-440-3000
Mailing Address - Street 1:4939 FOLKER ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1456
Mailing Address - Country:US
Mailing Address - Phone:907-440-3000
Mailing Address - Fax:
Practice Address - Street 1:4939 FOLKER ST UNIT A
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-1456
Practice Address - Country:US
Practice Address - Phone:907-440-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health