Provider Demographics
NPI:1215069414
Name:DENALI MESA CORPORATION
Entity type:Organization
Organization Name:DENALI MESA CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:KINNEBREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-258-8618
Mailing Address - Street 1:907 E DOWLING RD
Mailing Address - Street 2:STE 26
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-1424
Mailing Address - Country:US
Mailing Address - Phone:907-258-8618
Mailing Address - Fax:907-563-9291
Practice Address - Street 1:260 CAVIAR ST
Practice Address - Street 2:STE A
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7738
Practice Address - Country:US
Practice Address - Phone:907-258-8618
Practice Address - Fax:907-563-9291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKTC6852Medicaid
AK193978502OtherDEPARTMENT OF LABOR
AKTC6852Medicaid