Basic Information
| Provider Information | |||||||||
| NPI: | 1851336176 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEACEHEALTH | ||||||||
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| OtherOrganizationName: | KETCHIKAN GEN HOSP LTC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1798 | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982271798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072288300 | ||||||||
| FaxNumber: | 9072288518 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 TONGASS AVE | ||||||||
| Address2: | |||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999015746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072288300 | ||||||||
| FaxNumber: | 9072288518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 09/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | BRANCO | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9072288300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KETCHIKAN GENERAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NO NUMBER ASSIGNED | AK | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | HS04LT | 05 | AK | MEDICAID |