1104083419 NPI number — LOU J KUCHENOFF CHA-III

Table of content: LOU J KUCHENOFF CHA-III (NPI 1104083419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104083419 NPI number — LOU J KUCHENOFF CHA-III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUCHENOFF
Provider First Name:
LOU
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CHA-III
Provider Gender Code:
F

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:
1104083419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3380 C ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99503-3949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-277-1440
Provider Business Mailing Address Fax Number:
907-277-1436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
172 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAND POINT
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-383-3151
Provider Business Practice Location Address Fax Number:
907-383-5688
Provider Enumeration Date:
05/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 172V00000X , 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: MDG926 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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