Provider Demographics
NPI:1720614993
Name:PENINSULA INSTACARE
Entity Type:Organization
Organization Name:PENINSULA INSTACARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:UDELHOVEN
Authorized Official - Suffix:
Authorized Official - Credentials:PA,C
Authorized Official - Phone:907-420-0575
Mailing Address - Street 1:34581 KENAI SPUR HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669
Mailing Address - Country:US
Mailing Address - Phone:907-420-0575
Mailing Address - Fax:907-420-0525
Practice Address - Street 1:34581 KENAI SPUR HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669
Practice Address - Country:US
Practice Address - Phone:907-420-0575
Practice Address - Fax:907-420-0525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-19
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1572984Medicaid