Provider Demographics
NPI:1851336176
Name:PEACEHEALTH
Entity Type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:KETCHIKAN GEN HOSP LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRANCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-228-8300
Mailing Address - Street 1:PO BOX 1798
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-1798
Mailing Address - Country:US
Mailing Address - Phone:907-228-8300
Mailing Address - Fax:907-228-8518
Practice Address - Street 1:3100 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5746
Practice Address - Country:US
Practice Address - Phone:907-228-8300
Practice Address - Fax:907-228-8518
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KETCHIKAN GENERAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-19
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKNO NUMBER ASSIGNED314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHS04LTMedicaid
AKHS04LTMedicaid