Provider Demographics
NPI:1811596026
Name:PIVOTAL CARE PARTNERSHIP LLC
Entity Type:Organization
Organization Name:PIVOTAL CARE PARTNERSHIP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVELOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-375-2025
Mailing Address - Street 1:PO BOX 90812
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99509-0812
Mailing Address - Country:US
Mailing Address - Phone:907-375-2025
Mailing Address - Fax:
Practice Address - Street 1:2925 DEBARR RD STE 199
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2959
Practice Address - Country:US
Practice Address - Phone:907-632-5057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-19
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1588968945Medicaid