Provider Demographics
NPI:1700143211
Name:SHANGRI'LA RANCH
Entity Type:Organization
Organization Name:SHANGRI'LA RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:KARMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPARKS BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-687-7775
Mailing Address - Street 1:PO BOX 56776
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-1776
Mailing Address - Country:US
Mailing Address - Phone:907-687-7775
Mailing Address - Fax:
Practice Address - Street 1:782 ADVENTURE RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99712-3330
Practice Address - Country:US
Practice Address - Phone:907-687-7775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK251C00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care