Provider Demographics
NPI:1730388190
Name:DIANE MARIE BOYER
Entity type:Organization
Organization Name:DIANE MARIE BOYER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-892-0794
Mailing Address - Street 1:PO BOX 520983
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:AK
Mailing Address - Zip Code:99652
Mailing Address - Country:US
Mailing Address - Phone:907-892-0794
Mailing Address - Fax:907-892-0795
Practice Address - Street 1:11269 WEST WASEY WAY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:AK
Practice Address - Zip Code:99694
Practice Address - Country:US
Practice Address - Phone:907-892-0794
Practice Address - Fax:907-892-0795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK739433251E00000X
AK310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL2365Medicaid