1699216606 NPI number — ENRICHMENT CENTER FOR MATURE ADULTS, LLC

Table of content: (NPI 1699216606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699216606 NPI number — ENRICHMENT CENTER FOR MATURE ADULTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENRICHMENT CENTER FOR MATURE ADULTS, LLC
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:
1699216606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2207 E TUDOR RD STE 33
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:
99507-1069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-561-1083
Provider Business Mailing Address Fax Number:
907-561-1075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2207 E TUDOR RD STE 33
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:
99507-1069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-561-1083
Provider Business Practice Location Address Fax Number:
907-561-1075
Provider Enumeration Date:
03/10/2017

Additional Information

Authorized Official

Authorized Official Last Name:
XIONG
Authorized Official First Name:
TOU
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
907-561-1083

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

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




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