Provider Demographics
NPI:1902123508
Name:ARCTIC HAVEN ASSISTED LIVING HOME INC
Entity Type:Organization
Organization Name:ARCTIC HAVEN ASSISTED LIVING HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES - ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYLA GRACIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GATPANDAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:907-240-7519
Mailing Address - Street 1:3300 E 15TH AVE # 2
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-3005
Mailing Address - Country:US
Mailing Address - Phone:907-258-0197
Mailing Address - Fax:
Practice Address - Street 1:3300 E 15TH AVE # 2
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3005
Practice Address - Country:US
Practice Address - Phone:907-258-0197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK936586310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL 85611Medicaid