Provider Demographics
NPI:1013237635
Name:LILLEY LODGE 1, LLC
Entity Type:Organization
Organization Name:LILLEY LODGE 1, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:GAINER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:907-347-1489
Mailing Address - Street 1:PO BOX 56709
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-1709
Mailing Address - Country:US
Mailing Address - Phone:907-347-1489
Mailing Address - Fax:907-490-0322
Practice Address - Street 1:2330 OLD RICHARDSON HWY
Practice Address - Street 2:
Practice Address - City:NORTH POLE
Practice Address - State:AK
Practice Address - Zip Code:99705-6017
Practice Address - Country:US
Practice Address - Phone:907-347-1489
Practice Address - Fax:907-490-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100797310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility