Provider Demographics
NPI:1700563301
Name:BIG LAKE COUNTRY CLUB, LLC
Entity Type:Organization
Organization Name:BIG LAKE COUNTRY CLUB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:GEDDES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-250-6605
Mailing Address - Street 1:PO BOX 520069
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:AK
Mailing Address - Zip Code:99652-0069
Mailing Address - Country:US
Mailing Address - Phone:907-232-8466
Mailing Address - Fax:
Practice Address - Street 1:12528 W. HAWK LANE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:AK
Practice Address - Zip Code:99694
Practice Address - Country:US
Practice Address - Phone:907-232-8466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BIG LAKE COUNTRY CLUB LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities