Provider Demographics
NPI:1174718696
Name:SOUTHPORT ALH
Entity type:Organization
Organization Name:SOUTHPORT ALH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JOSEFINA
Authorized Official - Middle Name:G
Authorized Official - Last Name:ISLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-360-6621
Mailing Address - Street 1:10530 CONSTITUTION ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-2510
Mailing Address - Country:US
Mailing Address - Phone:907-349-1402
Mailing Address - Fax:
Practice Address - Street 1:10530 CONSTITUTION ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-2510
Practice Address - Country:US
Practice Address - Phone:907-349-1402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility