Basic Information
| Provider Information | |||||||||
| NPI: | 1932312485 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH EAST ALASKA REGIONAL HEALTH CONSORTIUM | ||||||||
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| OtherOrganizationName: | WILDFLOWER COURT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 CHANNEL DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074634074 | ||||||||
| FaxNumber: | 9074631510 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 SALMON CREEK LANE | ||||||||
| Address2: | 2000 SALMON CREEK LANE | ||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074638700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 05/25/2017 | ||||||||
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| AuthorizedOfficialLastName: | NEUMEISTER | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9074634000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 70206 | AK | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | MDG628 | 05 | AK | MEDICAID |