Provider Demographics
NPI:1912022948
Name:SUNSET DEVELOPMENT CO OF KODIAK
Entity Type:Organization
Organization Name:SUNSET DEVELOPMENT CO OF KODIAK
Other - Org Name:BAYVIEW TERRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-481-1607
Mailing Address - Street 1:309 ERSKINE AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6390
Mailing Address - Country:US
Mailing Address - Phone:907-481-1607
Mailing Address - Fax:
Practice Address - Street 1:309 ERSKINE AVE APT 208
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6390
Practice Address - Country:US
Practice Address - Phone:907-481-1607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHC9400Medicaid