Provider Demographics
NPI:1215061205
Name:NORTHSTAR ASSISTED LIVING, INC.
Entity type:Organization
Organization Name:NORTHSTAR ASSISTED LIVING, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER, PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HERVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-357-2012
Mailing Address - Street 1:PO BOX 872889
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-2889
Mailing Address - Country:US
Mailing Address - Phone:907-357-2019
Mailing Address - Fax:
Practice Address - Street 1:4070 S BIRCH COVE DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-9456
Practice Address - Country:US
Practice Address - Phone:907-357-2019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK000093310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHC 5642Medicaid
AKRL 5642Medicaid