Provider Demographics
NPI:1659601409
Name:NORTHERN LIGHTHOUSE DBA NORTHERN LIGHTHOUSE DAY CENTER
Entity Type:Organization
Organization Name:NORTHERN LIGHTHOUSE DBA NORTHERN LIGHTHOUSE DAY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:METTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-398-2939
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-0609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:136 E REDOUBT AVE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8012
Practice Address - Country:US
Practice Address - Phone:907-398-2939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN LIGHTHOUSE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKNONE ISSED BY STATE385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care