Provider Demographics
NPI:1295911212
Name:ELENAS PLACE CORPORATION
Entity type:Organization
Organization Name:ELENAS PLACE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:DOMONDON
Authorized Official - Last Name:REGACHO
Authorized Official - Suffix:
Authorized Official - Credentials:ELEMENTARY TEACHER
Authorized Official - Phone:907-336-9090
Mailing Address - Street 1:8611 ARCTIC BLVD # 1
Mailing Address - Street 2:SAME
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-1708
Mailing Address - Country:US
Mailing Address - Phone:907-336-9090
Mailing Address - Fax:907-336-9090
Practice Address - Street 1:8611 ARCTIC BLVD # 1
Practice Address - Street 2:SAME
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-1708
Practice Address - Country:US
Practice Address - Phone:907-336-9090
Practice Address - Fax:907-336-9090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK000156261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL82901Medicaid