Provider Demographics
NPI:1376075697
Name:SEVEN PRINCIPLES THERAPEUTICS
Entity Type:Organization
Organization Name:SEVEN PRINCIPLES THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ROLAND
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-342-9500
Mailing Address - Street 1:2901 ILLIAMNA AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99517-1219
Mailing Address - Country:US
Mailing Address - Phone:907-342-9500
Mailing Address - Fax:
Practice Address - Street 1:505 W NORTHERN LIGHTS BVLD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503
Practice Address - Country:US
Practice Address - Phone:907-302-8205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-28
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMEDS 7369261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK575135Medicaid
AK575135Medicaid