Provider Demographics
NPI:1962693812
Name:EDGAR LATTIMORES ASSISTED LIVING
Entity type:Organization
Organization Name:EDGAR LATTIMORES ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:LATTIMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-830-8365
Mailing Address - Street 1:6320 MINK AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-2527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6320 MINK AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-2527
Practice Address - Country:US
Practice Address - Phone:907-830-8365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100305251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK94063Medicaid