Provider Demographics
NPI:1023132784
Name:PETERSBURG BOROUGH
Entity type:Organization
Organization Name:PETERSBURG BOROUGH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHELYN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-772-2445
Mailing Address - Street 1:PO BOX 1530
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:AK
Mailing Address - Zip Code:99833-1530
Mailing Address - Country:US
Mailing Address - Phone:907-772-2445
Mailing Address - Fax:907-772-2435
Practice Address - Street 1:16 NORTH 12TH STREET
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:AK
Practice Address - Zip Code:99833-0000
Practice Address - Country:US
Practice Address - Phone:907-772-3445
Practice Address - Fax:907-772-4217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK00276310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL5005Medicaid