Organization
WASILLA GROUP HOME LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. RENNE CHAMPAGNE CNA (OWNER ADMINISTRATOR)
(907) 357-0102
Entity
Organization
Contact information
Practice address
3660 W LYNN DR, WASILLA, AK 99654-0949
(907) 357-0102
(907) 631-4253
Mailing address
3660 W LYNN DR, WASILLA, AK 99654-0949
(907) 357-0102
(907) 631-4253
Taxonomy
Speciality
Code
Description
License number
State
3104A0625X
Assisted Living Facility (Mental Illness)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1026476
—
AK
Enumeration date
08/01/2019
Last updated
08/01/2019
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