1659483113 NPI number — PROVIDENCE HEALTH & SERVICES - WASHINGTON

Table of content: (NPI 1659483113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659483113 NPI number — PROVIDENCE HEALTH & SERVICES - WASHINGTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTH & SERVICES - WASHINGTON
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:
PROVIDENCE ADOLESCENT RESIDENTIAL TREATMENT PROGRAM
Provider Other Organization Name Type Code:
3
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:
1659483113
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3760 PIPER ST
Provider Second Line Business Mailing Address:
SUITE 1061
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99508-4665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-212-0209
Provider Business Mailing Address Fax Number:
907-212-6547

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3210 W 62ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-212-2040
Provider Business Practice Location Address Fax Number:
907-272-2169
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
ASSISTANT SECRETARY OF ENROLLMENTS
Authorized Official Telephone Number:
425-525-5392

Provider Taxonomy Codes

  • Taxonomy code: 323P00000X , with the licence number:  400157 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: HS487PI , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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