Provider Demographics
NPI:1669935714
Name:LLOREN-PARIS, BERNADITH METUCUA
Entity type:Individual
Prefix:
First Name:BERNADITH
Middle Name:METUCUA
Last Name:LLOREN-PARIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 CHILKOOT CT
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-4319
Mailing Address - Country:US
Mailing Address - Phone:907-222-3490
Mailing Address - Fax:907-222-3490
Practice Address - Street 1:5535 CHILKOOT CT
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-4319
Practice Address - Country:US
Practice Address - Phone:907-222-3490
Practice Address - Fax:907-222-3490
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-06
Last Update Date:2019-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101302320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK048Medicaid