Provider Demographics
NPI:1104540087
Name:CORDIAL CARE ASSISTED LIVING HOME
Entity type:Organization
Organization Name:CORDIAL CARE ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HADDYJATOU
Authorized Official - Middle Name:BURANG
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-342-7385
Mailing Address - Street 1:3861 W 74TH AVE # A
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-2865
Mailing Address - Country:US
Mailing Address - Phone:907-644-6024
Mailing Address - Fax:
Practice Address - Street 1:3861 W 74TH AVE # A
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99502-2865
Practice Address - Country:US
Practice Address - Phone:907-644-6024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORDIAL CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health