Provider Demographics
NPI:1275754012
Name:PRESBYTERIAN HOSPITALITY HOUSE
Entity Type:Organization
Organization Name:PRESBYTERIAN HOSPITALITY HOUSE
Other - Org Name:BOYS FARM
Other - Org Type:Other Name
Authorized Official - Title/Position:EXCUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TIGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:907-456-6445
Mailing Address - Street 1:209 FORTY MILE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3110
Mailing Address - Country:US
Mailing Address - Phone:907-456-6446
Mailing Address - Fax:907-456-6402
Practice Address - Street 1:7609 CHENA HOT SPRINGS RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99712
Practice Address - Country:US
Practice Address - Phone:907-456-6446
Practice Address - Fax:907-456-6402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH2770Medicaid