Provider Demographics
NPI:1902364839
Name:BEAR LAKE ASSISTED LIVING HOME
Entity Type:Organization
Organization Name:BEAR LAKE ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:PULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-362-7773
Mailing Address - Street 1:PO BOX 336
Mailing Address - Street 2:
Mailing Address - City:SEWARD
Mailing Address - State:AK
Mailing Address - Zip Code:99664-0336
Mailing Address - Country:US
Mailing Address - Phone:907-362-7773
Mailing Address - Fax:
Practice Address - Street 1:33472 BEAR LAKE RD
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664-9604
Practice Address - Country:US
Practice Address - Phone:907-362-7773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK170375751Medicaid