Healthcare Provider Details

I. General information

NPI: 1366658858
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1838 CHICHENOF ST
KODIAK AK
99615-6519
US

IV. Provider business mailing address

1915 E REZANOF DR
KODIAK AK
99615-6602
US

V. Phone/Fax

Practice location:
  • Phone: 907-486-3281
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number309115
License Number StateAK

VIII. Authorized Official

Name: DONALD W ANDERSON JR.
Title or Position: ASSISTANT SECRETARY OF ENROLLMENTS
Credential:
Phone: 425-358-9786