Provider Demographics
NPI:1942785464
Name:BRANCHING OUT SUPPORTED SERVICES LLC
Entity Type:Organization
Organization Name:BRANCHING OUT SUPPORTED SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHTSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-987-9267
Mailing Address - Street 1:1584 HILTON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4016
Mailing Address - Country:US
Mailing Address - Phone:907-987-9267
Mailing Address - Fax:
Practice Address - Street 1:1584 HILTON AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4016
Practice Address - Country:US
Practice Address - Phone:907-987-9267
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-01
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities