Provider Demographics
NPI:1629281126
Name:THE MOOSE SHACK
Entity Type:Organization
Organization Name:THE MOOSE SHACK
Other - Org Name:AUTUMN SUNRISE ASSISTED LIVING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CANDIS
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:907-351-0569
Mailing Address - Street 1:19216 CITATION RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8416
Mailing Address - Country:US
Mailing Address - Phone:907-351-0569
Mailing Address - Fax:888-291-5028
Practice Address - Street 1:19216 CITATION RD
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8416
Practice Address - Country:US
Practice Address - Phone:907-351-0569
Practice Address - Fax:888-291-5028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK000277310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL09771Medicaid
AK1030021Medicaid