Provider Demographics
NPI:1801168620
Name:MCKENZIE ASSISTED LIVING
Entity type:Organization
Organization Name:MCKENZIE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-336-0080
Mailing Address - Street 1:8812 HAMLET CIR
Mailing Address - Street 2:8812 HAMLET CIRCLE
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-5551
Mailing Address - Country:US
Mailing Address - Phone:907-336-0080
Mailing Address - Fax:
Practice Address - Street 1:8812 HAMLET CIRCLE
Practice Address - Street 2:8812 HAMLET CIRCLE
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99502
Practice Address - Country:US
Practice Address - Phone:907-336-0080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100249261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health