Provider Demographics
NPI:1841568953
Name:ALPHA ADVANTAGE MCO
Entity Type:Organization
Organization Name:ALPHA ADVANTAGE MCO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JERETHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARBURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-468-7914
Mailing Address - Street 1:PO BOX 112243
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98411-2243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6108 COMMUNITY PL SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2447
Practice Address - Country:US
Practice Address - Phone:253-468-7914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602187014251300000X, 251X00000X, 302R00000X, 332BC3200X, 347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No251300000XAgenciesLocal Education Agency (LEA)
No251X00000XAgenciesSupports Brokerage
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA146954Medicaid