Provider Demographics
NPI:1285145193
Name:SERENE GRACE ASSISTED LIVING HOME LLC
Entity type:Organization
Organization Name:SERENE GRACE ASSISTED LIVING HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:MIRASOL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-272-4073
Mailing Address - Street 1:3639 E 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-2829
Mailing Address - Country:US
Mailing Address - Phone:907-272-4073
Mailing Address - Fax:907-522-1626
Practice Address - Street 1:3639 E 74TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-2829
Practice Address - Country:US
Practice Address - Phone:907-272-4073
Practice Address - Fax:907-522-1626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101199310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK101199OtherSTATE OF ALASKA
AK1051694OtherSTATE OF ALASKA