Provider Demographics
NPI:1598264715
Name:LAKE HAVEN HOMES, LLC
Entity Type:Organization
Organization Name:LAKE HAVEN HOMES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SOMMERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-841-1380
Mailing Address - Street 1:7362 W PARKS HWY # 638
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99623-9300
Mailing Address - Country:US
Mailing Address - Phone:907-841-1380
Mailing Address - Fax:
Practice Address - Street 1:7781 W DEAN DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-0824
Practice Address - Country:US
Practice Address - Phone:907-841-1380
Practice Address - Fax:907-841-1380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100183320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities