Provider Demographics
NPI:1336262542
Name:DIVINE MERCY ALH
Entity type:Organization
Organization Name:DIVINE MERCY ALH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIEZER
Authorized Official - Middle Name:
Authorized Official - Last Name:PENTECOSTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-868-8608
Mailing Address - Street 1:8100 PECK AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-1422
Mailing Address - Country:US
Mailing Address - Phone:907-868-8608
Mailing Address - Fax:
Practice Address - Street 1:8100 PECK AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-1422
Practice Address - Country:US
Practice Address - Phone:907-868-8608
Practice Address - Fax:907-868-8608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100397310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL2598Medicaid