Provider Demographics
NPI:1952323859
Name:PROVIDENCE HEALTH & SERVICES-WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES-WASHINGTON
Other - Org Name:PROVIDENCE HORIZON HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GLEASON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:907-261-4167
Mailing Address - Street 1:4140 FOLKER ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5323
Mailing Address - Country:US
Mailing Address - Phone:907-261-4140
Mailing Address - Fax:907-261-4160
Practice Address - Street 1:3760 PIPER ST
Practice Address - Street 2:SUITE 1061
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4683
Practice Address - Country:US
Practice Address - Phone:907-212-0256
Practice Address - Fax:907-212-6547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK279763310400000X, 311500000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1004814Medicaid
AK1030243Medicaid
AK1030242Medicaid