Healthcare Provider Details

I. General information

NPI: 1386117729
Provider Name (Legal Business Name): SPIRITUAL RESTORATION MINISTRY LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E 84TH AVE STE 203
ANCHORAGE AK
99507-3160
US

IV. Provider business mailing address

1601 E 84TH AVE STE 203
ANCHORAGE AK
99507-3160
US

V. Phone/Fax

Practice location:
  • Phone: 907-887-6584
  • Fax:
Mailing address:
  • Phone: 907-992-2320
  • Fax: 907-344-1134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CORDLES WALKER RODRIGUEZ
Title or Position: DEPUTY DIRECTOR
Credential: ETC
Phone: 907-992-2320