Organization
BIG LAKE COUNTRY CLUB
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JESS G ADAMS (STAFF OFFICE)
(907) 892-6944
Entity
Organization
Contact information
Practice address
12528 HAWK LANE, HOUSTON, AK 99694-2528
(907) 892-6944
Mailing address
PO BOX 299136, WASILLA, AK 99629-9136
(907) 892-6944
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
100554
AK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
HC78981
—
AK
Enumeration date
06/06/2008
Last updated
07/22/2009
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