Healthcare Provider Details

I. General information

NPI: 1831411826
Provider Name (Legal Business Name): BORE TIDE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22742 OBERG RD
CHUGIAK AK
99567-5495
US

IV. Provider business mailing address

PO BOX 220685
ANCHORAGE AK
99522-0685
US

V. Phone/Fax

Practice location:
  • Phone: 907-854-8452
  • Fax: 907-222-4641
Mailing address:
  • Phone: 907-677-2990
  • Fax: 907-222-4641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number633
License Number StateAK

VIII. Authorized Official

Name: MR. DENNIS S SERIE
Title or Position: PHYSICIAN ASSISTANT
Credential:
Phone: 907-677-2990