Provider Demographics
NPI:1790035087
Name:CARMELITE HOME
Entity Type:Organization
Organization Name:CARMELITE HOME
Other - Org Name:CARMELITE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AINA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-336-1296
Mailing Address - Street 1:9401 APHRODITE DR.
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515
Mailing Address - Country:US
Mailing Address - Phone:907-336-1296
Mailing Address - Fax:907-336-1298
Practice Address - Street 1:9401 APHRODITE DR.
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515
Practice Address - Country:US
Practice Address - Phone:907-336-1296
Practice Address - Fax:907-336-1298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100955320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRLXOtherHOME AND COMMUNITY BASED WAIVER PROGRAM