Provider Demographics
NPI:1255631446
Name:BOYS AND GIRLS HOME OF ALASKA
Entity type:Organization
Organization Name:BOYS AND GIRLS HOME OF ALASKA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:712-293-4700
Mailing Address - Street 1:3101 LATHROP ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7426
Mailing Address - Country:US
Mailing Address - Phone:712-293-4700
Mailing Address - Fax:712-293-4800
Practice Address - Street 1:3101 LATHROP ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7426
Practice Address - Country:US
Practice Address - Phone:712-293-4700
Practice Address - Fax:712-293-4800
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOYS AND GIRLS HOME AND FAMILY SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK513478320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness