Provider Demographics
NPI:1063259687
Name:KODIAK ISLAND ASSISTED LIVING, LLC
Entity type:Organization
Organization Name:KODIAK ISLAND ASSISTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY JEAN
Authorized Official - Middle Name:V
Authorized Official - Last Name:SILVA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:915-841-1117
Mailing Address - Street 1:914 THORSHEIM ST
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6165
Mailing Address - Country:US
Mailing Address - Phone:915-841-1117
Mailing Address - Fax:
Practice Address - Street 1:1814 SIMEONOF ST
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6517
Practice Address - Country:US
Practice Address - Phone:915-841-1117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care