Provider Demographics
NPI:1902518848
Name:BANYAN ALASKA, LLC
Entity Type:Organization
Organization Name:BANYAN ALASKA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING & CONTRAC
Authorized Official - Prefix:MR
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-533-7705
Mailing Address - Street 1:225 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-4319
Mailing Address - Country:US
Mailing Address - Phone:888-879-4975
Mailing Address - Fax:954-781-7173
Practice Address - Street 1:4750 E BEGICH CIRCLE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:888-879-4975
Practice Address - Fax:954-781-7173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-22
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder