=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215069414
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENALI MESA CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2007
-----------------------------------------------------
Last Update Date | 07/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 260 CAVIAR ST STE A
-----------------------------------------------------
City | KENAI
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99611-7738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-258-8618
-----------------------------------------------------
Fax | 907-563-9291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 907 E DOWLING RD STE 26
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99518-1424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-258-8618
-----------------------------------------------------
Fax | 907-563-9291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MR. PATRICK KINNEBREW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 907-258-8618
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------