Provider Demographics
NPI:1013135649
Name:BLUEBERRY LODGE B&B
Entity type:Organization
Organization Name:BLUEBERRY LODGE B&B
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:FAY
Authorized Official - Last Name:URQUHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-463-5886
Mailing Address - Street 1:9436 N DOUGLAS HWY
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7649
Mailing Address - Country:US
Mailing Address - Phone:907-463-5886
Mailing Address - Fax:907-463-5886
Practice Address - Street 1:9436 N DOUGLAS HWY
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7649
Practice Address - Country:US
Practice Address - Phone:907-463-5886
Practice Address - Fax:907-463-5886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100284320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHC5192Medicaid