1265616783 NPI number — KAREN PUDGE DBA FORGET-ME-NOT CARE COORDINATION

Table of content: (NPI 1265616783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265616783 NPI number — KAREN PUDGE DBA FORGET-ME-NOT CARE COORDINATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KAREN PUDGE DBA FORGET-ME-NOT CARE COORDINATION
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:
6
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:
1265616783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 110297
Provider Second Line Business Mailing Address:
FOREGET-ME-NOT CARE COORDINATION
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99511-0297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-646-9877
Provider Business Mailing Address Fax Number:
907-646-1991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4350 E 145TH AVENUE
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:
99516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-646-9877
Provider Business Practice Location Address Fax Number:
907-646-1991
Provider Enumeration Date:
12/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PUDGE
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
LOUISE
Authorized Official Title or Position:
SOLE EMPLOYEE PROPRIETOR
Authorized Official Telephone Number:
907-646-9877

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X , with the licence number:  746363 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X , with the licence number: 746363 , 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: CM861611588848097 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: CMG8611265616783 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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