Provider Demographics
NPI:1770918732
Name:PROVIDENCE HEALTH AND SERVICES
Entity type:Organization
Organization Name:PROVIDENCE HEALTH AND SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH REHABILITION AIDE
Authorized Official - Prefix:
Authorized Official - First Name:DARCI
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:
Authorized Official - Credentials:RA
Authorized Official - Phone:907-481-2421
Mailing Address - Street 1:3431 ANTONE WAY
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-7124
Mailing Address - Country:US
Mailing Address - Phone:907-481-2421
Mailing Address - Fax:907-481-2419
Practice Address - Street 1:717 REZANOF DR E
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6416
Practice Address - Country:US
Practice Address - Phone:907-481-2421
Practice Address - Fax:907-481-2419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health