Provider Demographics
NPI:1710195193
Name:GRANDMA K'S PLACE
Entity Type:Organization
Organization Name:GRANDMA K'S PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:THELMA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:DUBYAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-522-1958
Mailing Address - Street 1:3832 YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4548
Mailing Address - Country:US
Mailing Address - Phone:907-522-1958
Mailing Address - Fax:
Practice Address - Street 1:3832 YOUNG ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4548
Practice Address - Country:US
Practice Address - Phone:907-522-1958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK000287310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL19691Medicaid