Provider Demographics
NPI:1699320127
Name:WASILLA GROUP HOME LLC
Entity type:Organization
Organization Name:WASILLA GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMPAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:907-357-0102
Mailing Address - Street 1:3660 W LYNN DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-0949
Mailing Address - Country:US
Mailing Address - Phone:907-357-0102
Mailing Address - Fax:907-631-4253
Practice Address - Street 1:3660 W LYNN DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-0949
Practice Address - Country:US
Practice Address - Phone:907-357-0102
Practice Address - Fax:907-631-4253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1026476Medicaid