Provider Demographics
NPI:1821126145
Name:HOUSE OF SHALOM LLC
Entity Type:Organization
Organization Name:HOUSE OF SHALOM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-222-4868
Mailing Address - Street 1:2608 FRIGATE CIR
Mailing Address - Street 2:2608 FRIGATE CIR
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-2569
Mailing Address - Country:US
Mailing Address - Phone:907-222-4868
Mailing Address - Fax:
Practice Address - Street 1:2608 FRIGATE CIR
Practice Address - Street 2:2608 FRIGATE CIR
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-2569
Practice Address - Country:US
Practice Address - Phone:907-222-4868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10051310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL2318Medicaid