Provider Demographics
NPI:1831411826
Name:BORE TIDE SERVICES, LLC
Entity type:Organization
Organization Name:BORE TIDE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:S
Authorized Official - Last Name:SERIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-677-2990
Mailing Address - Street 1:PO BOX 220685
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99522-0685
Mailing Address - Country:US
Mailing Address - Phone:907-677-2990
Mailing Address - Fax:907-222-4641
Practice Address - Street 1:22742 OBERG RD
Practice Address - Street 2:
Practice Address - City:CHUGIAK
Practice Address - State:AK
Practice Address - Zip Code:99567-5495
Practice Address - Country:US
Practice Address - Phone:907-854-8452
Practice Address - Fax:907-222-4641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK633363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDA0081Medicaid
AKMDA0081Medicaid