Provider Demographics
NPI:1255528733
Name:KENAI FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:KENAI FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:907-335-0034
Mailing Address - Street 1:135 BIDARKA ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7741
Mailing Address - Country:US
Mailing Address - Phone:907-335-0034
Mailing Address - Fax:907-335-0064
Practice Address - Street 1:135 BIDARKA ST
Practice Address - Street 2:SUITE 101
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7741
Practice Address - Country:US
Practice Address - Phone:907-335-0034
Practice Address - Fax:907-335-0064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK175363L00000X
AK725363A00000X
AK4040207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK152261OtherMEDICARE GROUP LEGACY