Basic Information
| Provider Information | |||||||||
| NPI: | 1093935728 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTERNATIVE COMMUNITY ENRICHMENT SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ACES COMMUNITY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1417 N 4TH STREET | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082922188 | ||||||||
| FaxNumber: | 2082922189 | ||||||||
| Practice Location | |||||||||
| Address1: | 1417 N 4TH STREET | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082922188 | ||||||||
| FaxNumber: | 2082922189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 05/10/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/09/2011 | ||||||||
| NPIReactivationDate: | 05/02/2011 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2082922188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 104100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 806431100 | 01 | ID | CDA-MHC | OTHER |