Provider Demographics
NPI:1750567640
Name:MAT-SU VALLEY II LLC
Entity type:Organization
Organization Name:MAT-SU VALLEY II LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR BUSINESS SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7466
Mailing Address - Street 1:950 E BOGARD RD
Mailing Address - Street 2:SUITE 132
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 E BOGARD RD
Practice Address - Street 2:SUITE 132
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7105
Practice Address - Country:US
Practice Address - Phone:907-861-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK297764251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK021500Medicare Oscar/Certification