Provider Demographics
NPI:1467648402
Name:KIDS BEHAVIORAL HEALTH OF ALASKA, INC.
Entity Type:Organization
Organization Name:KIDS BEHAVIORAL HEALTH OF ALASKA, INC.
Other - Org Name:COPPER HILLS YOUTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CSW
Authorized Official - Phone:801-561-3377
Mailing Address - Street 1:5899 RIVENDELL DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5700
Mailing Address - Country:US
Mailing Address - Phone:801-561-3377
Mailing Address - Fax:801-569-3274
Practice Address - Street 1:5899 RIVENDELL DR
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5700
Practice Address - Country:US
Practice Address - Phone:801-561-3377
Practice Address - Fax:801-569-3274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13093322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHS825PIMedicaid
AZ596661Medicaid
NM98139363Medicaid