Healthcare Provider Details

I. General information

NPI: 1023132784
Provider Name (Legal Business Name): PETERSBURG BOROUGH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 NORTH 12TH STREET
PETERSBURG AK
99833-0000
US

IV. Provider business mailing address

PO BOX 1530
PETERSBURG AK
99833-1530
US

V. Phone/Fax

Practice location:
  • Phone: 907-772-3445
  • Fax: 907-772-4217
Mailing address:
  • Phone: 907-772-2445
  • Fax: 907-772-2435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number00276
License Number StateAK

VIII. Authorized Official

Name: SHELYN MARIE BELL
Title or Position: DIRECTOR/ADMINISTRATOR
Credential:
Phone: 907-772-2445