Provider Demographics
NPI:1558561837
Name:KEITH C BODLEY
Entity Type:Organization
Organization Name:KEITH C BODLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:C
Authorized Official - Last Name:BODLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-868-8661
Mailing Address - Street 1:PO BOX 233322
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99523-3322
Mailing Address - Country:US
Mailing Address - Phone:907-868-8661
Mailing Address - Fax:907-868-8661
Practice Address - Street 1:12501 SILVER FOX LN
Practice Address - Street 2:APARTMENT #1
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-3527
Practice Address - Country:US
Practice Address - Phone:907-868-8661
Practice Address - Fax:907-868-8661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK171M00000XMedicaid