Provider Demographics
NPI:1174644355
Name:TAVIRA-DEAN, ANGELES M (DIRECTOR, OWNER)
Entity Type:Individual
Prefix:
First Name:ANGELES
Middle Name:M
Last Name:TAVIRA-DEAN
Suffix:
Gender:F
Credentials:DIRECTOR, OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 WINTERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-3069
Mailing Address - Country:US
Mailing Address - Phone:907-770-6315
Mailing Address - Fax:907-770-1241
Practice Address - Street 1:1301 WINTERGREEN ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3069
Practice Address - Country:US
Practice Address - Phone:907-770-6315
Practice Address - Fax:907-770-1241
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK436017251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPCG224Medicaid