Wasilla Group Home LLC

Primary specialty

Assisted Living Facility (Mental Illness)Taxonomy code 3104A0625X

Legal business name

WASILLA GROUP HOME LLC

Practice address

3660 W Lynn Dr
Wasilla, AK 99654-0949

Phone

(907) 357-0102

Fax

(907) 631-4253

NPI assigned

Aug 1, 2019

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Renne Champagne, CNA

Title

Owner Administrator

Phone

(907) 357-0102

Specialties & licenses 1

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1564617600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1564617600000",
    "number": "1699320127",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3660 W LYNN DR",
            "city": "WASILLA",
            "state": "AK",
            "postal_code": "996540949",
            "telephone_number": "907-357-0102",
            "fax_number": "907-631-4253"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3660 W LYNN DR",
            "city": "WASILLA",
            "state": "AK",
            "postal_code": "996540949",
            "telephone_number": "907-357-0102",
            "fax_number": "907-631-4253"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WASILLA GROUP HOME LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-08-01",
        "last_updated": "2019-08-01",
        "status": "A",
        "authorized_official_last_name": "CHAMPAGNE",
        "authorized_official_first_name": "RENNE",
        "authorized_official_title_or_position": "OWNER ADMINISTRATOR",
        "authorized_official_telephone_number": "907-357-0102",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "CNA"
    },
    "taxonomies": [
        {
            "code": "3104A0625X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility, Assisted Living, Mental Illness",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1026476",
            "state": "AK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Bobbie Lee Washington Jr.
• Wasilla Area Seniors Inc
• Wasilla Area Seniors Inc.
• Wasilla Area Seniors Inc.
• Wasilla Chiropractic Clinic
• Wasilla Internal Medicine LLC
• Wasilla Physical Therapy Inc.
• Georgianna Waterer
• Lisa Lynn Waters, RN
• Rebecca Ellen Waters, CMT

• All providers in Wasilla, AK
• Assisted Living Facility (Mental Illness) in Alaska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 1, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.