Provider Demographics
NPI:1619186145
Name:PALS PALACE ASSISTANT LIVING HOME
Entity Type:Organization
Organization Name:PALS PALACE ASSISTANT LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHUANPIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPASORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-569-3022
Mailing Address - Street 1:2220 E 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2220 E 53RD AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-1661
Practice Address - Country:US
Practice Address - Phone:907-569-3022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK000162310400000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK310400000XMedicaid
AK311Z00000XMedicaid
AK385H00000XMedicaid