Provider Demographics
NPI:1255761987
Name:JEWEL LAKE ASSISTED LIVING HOME LLC
Entity type:Organization
Organization Name:JEWEL LAKE ASSISTED LIVING HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:REYES
Authorized Official - Last Name:BONGLO
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:907-243-9570
Mailing Address - Street 1:4132 WEST 88TH AVE.
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502
Mailing Address - Country:US
Mailing Address - Phone:907-243-9570
Mailing Address - Fax:907-245-0035
Practice Address - Street 1:4132 W 88TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99502-5107
Practice Address - Country:US
Practice Address - Phone:907-243-9570
Practice Address - Fax:907-245-0035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101014310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility