1720255946 NPI number — DENALI MESA CORPORATION

Table of content: (NPI 1720255946)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720255946 NPI number — DENALI MESA CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENALI MESA CORPORATION
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:
1720255946
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
907 E DOWLING RD
Provider Second Line Business Mailing Address:
STE 26
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99518-1424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-258-8618
Provider Business Mailing Address Fax Number:
907-563-9291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9109 MENDENHALL MALL RD
Provider Second Line Business Practice Location Address:
STE 5K
Provider Business Practice Location Address City Name:
JUNEAU
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99801-7113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-209-8571
Provider Business Practice Location Address Fax Number:
907-586-6736
Provider Enumeration Date:
05/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KINNEBREW
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
Authorized Official Title or Position:
OPERATIONS MANAGER
Authorized Official Telephone Number:
907-258-8618

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , 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: PT06931 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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