Provider Demographics
NPI:1528358207
Name:DIVINE MERCY II ALH, LLC
Entity Type:Organization
Organization Name:DIVINE MERCY II ALH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIEZER
Authorized Official - Middle Name:LIMUN
Authorized Official - Last Name:PENTECOSTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-868-8608
Mailing Address - Street 1:3554 NEWCOMB DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4852
Mailing Address - Country:US
Mailing Address - Phone:907-868-8608
Mailing Address - Fax:
Practice Address - Street 1:417 E 11TH AVE APT 5
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-4560
Practice Address - Country:US
Practice Address - Phone:907-770-9148
Practice Address - Fax:907-770-9149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100892310400000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1528358207Medicaid