Provider Demographics
NPI:1952440570
Name:KENAI PENINSULA COMMUNITY CARE CENTER
Entity Type:Organization
Organization Name:KENAI PENINSULA COMMUNITY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-283-7635
Mailing Address - Street 1:320 S SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7939
Mailing Address - Country:US
Mailing Address - Phone:907-283-7635
Mailing Address - Fax:907-283-9575
Practice Address - Street 1:320 S SPRUCE ST
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7939
Practice Address - Country:US
Practice Address - Phone:907-283-7635
Practice Address - Fax:907-283-9575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK311415322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children