Provider Demographics
NPI:1992067912
Name:LOUISA'S LEGACY
Entity type:Organization
Organization Name:LOUISA'S LEGACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAN MIGUEL
Authorized Official - Suffix:
Authorized Official - Credentials:CC
Authorized Official - Phone:907-771-4010
Mailing Address - Street 1:PO BOX 230482
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99523-0482
Mailing Address - Country:US
Mailing Address - Phone:907-771-4010
Mailing Address - Fax:907-771-4020
Practice Address - Street 1:555 W NORTHERN LIGHTS BLVD
Practice Address - Street 2:#234
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2501
Practice Address - Country:US
Practice Address - Phone:907-771-4010
Practice Address - Fax:907-771-4020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management