Provider Demographics
NPI:1598978983
Name:ROTARY HOUSE OF KETCHIKAN INC
Entity type:Organization
Organization Name:ROTARY HOUSE OF KETCHIKAN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRANCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-228-8300
Mailing Address - Street 1:2417 TONGASS AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5900
Mailing Address - Country:US
Mailing Address - Phone:907-225-5131
Mailing Address - Fax:
Practice Address - Street 1:320 BAWDEN ST
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-6503
Practice Address - Country:US
Practice Address - Phone:907-225-5131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK222744251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHM2227Medicaid