Provider Demographics
NPI:1376638171
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:PROVIDENCE EXTENDED CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMOUREUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-212-5682
Mailing Address - Street 1:PO BOX 196276
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99519-6276
Mailing Address - Country:US
Mailing Address - Phone:907-212-6522
Mailing Address - Fax:907-212-6593
Practice Address - Street 1:4900 EAGLE ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-7446
Practice Address - Country:US
Practice Address - Phone:907-562-2281
Practice Address - Fax:907-762-0266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKNOT NUMBERED314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDG231Medicaid
AKMDG231Medicaid
AKDB6719Medicare ID - Type UnspecifiedRAILROAD MEDICARE GROUP