Basic Information
| Provider Information | |||||||||
| NPI: | 1679067888 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ARCTIC WOLFE ASSISTED LIVING | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ARCTIC WOLFE ASSISTED LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 221876 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995221876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073171220 | ||||||||
| FaxNumber: | 9079295858 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 CROSS RD | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995153904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079292828 | ||||||||
| FaxNumber: | 9079295858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2018 | ||||||||
| LastUpdateDate: | 06/20/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOLFE | ||||||||
| AuthorizedOfficialFirstName: | OLAIDE | ||||||||
| AuthorizedOfficialMiddleName: | TEMITOPE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9073171220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ASSISTEDCARE SERVICES LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LMSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 101276 | AK | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 101276 | 01 | AK | ALASKA RESIDENTIAL LICENSE NUMBER | OTHER |