Provider Demographics
NPI:1760427082
Name:PEACEHEALTH
Entity Type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:KETCHIKAN MEDICAL CENTER HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SYS VP FIN INTEGRIT/CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIRER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-729-1132
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 328
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8003
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:212 CARLANNA LAKE RD STE 100
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5642
Practice Address - Country:US
Practice Address - Phone:907-225-8914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KETCHIKAN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-19
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKNO NUMBER ASSIGNED251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHH5794Medicaid
AKHH5794Medicaid