Basic Information
| Provider Information | |||||||||
| NPI: | 1255302386 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILDFLOWER COURT INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 SALMON CREEK LN | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074638700 | ||||||||
| FaxNumber: | 9074638743 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 SALMON CREEK LN | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074638700 | ||||||||
| FaxNumber: | 9074638743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | RUTH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9074638712 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 277668 | AK | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | LTO153 | 05 | AK | MEDICAID |