Provider Demographics
NPI:1700591831
Name:BOREALIS LIFE, LLC
Entity Type:Organization
Organization Name:BOREALIS LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRITNI
Authorized Official - Middle Name:
Authorized Official - Last Name:STICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-206-4689
Mailing Address - Street 1:2501 E 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 E 42ND AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5369
Practice Address - Country:US
Practice Address - Phone:907-206-4689
Practice Address - Fax:907-206-7426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-23
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty