Healthcare Provider Details

I. General information

NPI: 1952440570
Provider Name (Legal Business Name): KENAI PENINSULA COMMUNITY CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 S SPRUCE ST
KENAI AK
99611-7939
US

IV. Provider business mailing address

320 S SPRUCE ST
KENAI AK
99611-7939
US

V. Phone/Fax

Practice location:
  • Phone: 907-283-7635
  • Fax: 907-283-9575
Mailing address:
  • Phone: 907-283-7635
  • Fax: 907-283-9575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number311415
License Number StateAK

VIII. Authorized Official

Name: MISS TAMARA J. BIDWELL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 907-283-7635