Provider Demographics
NPI:1013137348
Name:ALICE SHANTZ
Entity type:Organization
Organization Name:ALICE SHANTZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHANTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-543-3232
Mailing Address - Street 1:PO BOX 1915
Mailing Address - Street 2:473 RIDGECREST DRIVE
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-1915
Mailing Address - Country:US
Mailing Address - Phone:907-543-3232
Mailing Address - Fax:907-543-1443
Practice Address - Street 1:473 RIDGECREST DRIVE
Practice Address - Street 2:BOX 1915
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-1915
Practice Address - Country:US
Practice Address - Phone:907-543-3232
Practice Address - Fax:907-543-1443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK432920177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes177F00000XOther Service ProvidersLodgingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHM3180Medicaid