Basic Information
| Provider Information | |||||||||
| NPI: | 1407907629 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALMER SENIOR CITIZENS CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 831 S CHUGACH ST | ||||||||
| Address2: | |||||||||
| City: | PALMER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996456605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077455454 | ||||||||
| FaxNumber: | 9077465173 | ||||||||
| Practice Location | |||||||||
| Address1: | 831 S CHUGACH ST | ||||||||
| Address2: | |||||||||
| City: | PALMER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996456605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077455454 | ||||||||
| FaxNumber: | 9077465173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TUBBS | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9077455454 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 261860 | AK | X | Agencies | Case Management | 251V00000X | 261859 | AK | X | Agencies | Voluntary or Charitable | 261Q00000X | 261859 | AK | X | Ambulatory Health Care Facilities | Clinic/Center | 261QA0600X | 283892 | AK | X | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | 343900000X | 261861 | AK | X | Transportation Services | Non-emergency Medical Transport (VAN) |
ID Information
| ID | Type | State | Issuer | Description | HC7853 | 05 | AK | MEDICAID | TX6161 | 05 | AK | MEDICAID | CMG503 | 05 | AK | MEDICAID |