Provider Demographics
NPI:1255454377
Name:MARIA ANGELICA ASSISTED LIVING HOME
Entity type:Organization
Organization Name:MARIA ANGELICA ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-563-6435
Mailing Address - Street 1:4121 GRAPE PLACE #1
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5174
Mailing Address - Country:US
Mailing Address - Phone:907-563-6435
Mailing Address - Fax:907-770-1168
Practice Address - Street 1:4121 GRAPE PLACE #1
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5174
Practice Address - Country:US
Practice Address - Phone:907-563-6435
Practice Address - Fax:907-770-1168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK000115310400000X, 311ZA0620X
AK434978311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Not Answered311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL7858OtherFIRST HEALTH PROVIDER NUM