Basic Information
| Provider Information | |||||||||
| NPI: | 1295956266 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTERNATIVE COMMUNITY ENRICHMENT SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ACES COMMUNITY SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1103 E SHERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838144154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082922188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1103 E SHERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838144154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082922188 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 05/10/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/09/2011 | ||||||||
| NPIReactivationDate: | 05/10/2011 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FAIRCHILD | ||||||||
| AuthorizedOfficialFirstName: | JEANETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE AUDITOR | ||||||||
| AuthorizedOfficialTelephone: | 2087625433 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 806383200 | 01 | ID | CDA-PSR | OTHER |