1407907629 NPI number — PALMER SENIOR CITIZENS CENTER, INC.

Table of content: (NPI 1407907629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407907629 NPI number — PALMER SENIOR CITIZENS CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALMER SENIOR CITIZENS CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407907629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
831 S CHUGACH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALMER
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99645-6605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-745-5454
Provider Business Mailing Address Fax Number:
907-746-5173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
831 S CHUGACH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALMER
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99645-6605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-745-5454
Provider Business Practice Location Address Fax Number:
907-746-5173
Provider Enumeration Date:
01/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TUBBS
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
907-745-5454

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  261860 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 251V00000X , with the licence number: 261859 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261Q00000X , with the licence number: 261859 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QA0600X , with the licence number: 283892 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 343900000X , with the licence number: 261861 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HC7853 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: TX6161 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: CMG503 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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