Provider Demographics
NPI:1891906095
Name:IMMACULATED CONCEPCION
Entity Type:Organization
Organization Name:IMMACULATED CONCEPCION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:JEANEPHERE
Authorized Official - Middle Name:HILARIO
Authorized Official - Last Name:LORENZANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-332-0158
Mailing Address - Street 1:1836 LAURA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-3516
Mailing Address - Country:US
Mailing Address - Phone:907-332-0158
Mailing Address - Fax:907-332-0958
Practice Address - Street 1:1836 LAURA CIRCLE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3516
Practice Address - Country:US
Practice Address - Phone:907-332-0158
Practice Address - Fax:907-332-0958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-27
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100549310400000X
AK7090913343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL 7902Medicaid