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General NPI Number Information
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NPI Number | 1952440570
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Entity Type | Organization
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Legal Business Name | KENAI PENINSULA COMMUNITY CARE CENTER
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 320 S SPRUCE ST
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City | KENAI
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State | AK
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Zip | 99611-7939
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Country | US
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Telephone | 907-283-7635
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Fax | 907-283-9575
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Provider Business Mailing Address
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Address Line | 320 S SPRUCE ST
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City | KENAI
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State | AK
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Zip | 99611-7939
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Country | US
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Telephone | 907-283-7635
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Fax | 907-283-9575
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MISS TAMARA J. BIDWELL
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Credential |
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Telephone | 907-283-7635
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 311415
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License Number State | AK
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