Healthcare Provider Details

I. General information

NPI: 1699252577
Provider Name (Legal Business Name): HAVEN ALAKSA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 L ST
ANCHORAGE AK
99501-1924
US

IV. Provider business mailing address

419 L ST
ANCHORAGE AK
99501-1924
US

V. Phone/Fax

Practice location:
  • Phone: 907-272-4411
  • Fax: 907-272-4412
Mailing address:
  • Phone: 907-272-4411
  • Fax: 907-272-4412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number118712
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number118712
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number118712
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateAK

VIII. Authorized Official

Name: MR. DAVE GUTHRIE
Title or Position: DIRECTOR
Credential: PASTOR
Phone: 907-272-4411