Provider Demographics
NPI:1699216606
Name:ENRICHMENT CENTER FOR MATURE ADULTS, LLC
Entity type:Organization
Organization Name:ENRICHMENT CENTER FOR MATURE ADULTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TOU
Authorized Official - Middle Name:
Authorized Official - Last Name:XIONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-561-1083
Mailing Address - Street 1:2207 E TUDOR RD STE 33
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1069
Mailing Address - Country:US
Mailing Address - Phone:907-561-1083
Mailing Address - Fax:907-561-1075
Practice Address - Street 1:2207 E TUDOR RD STE 33
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-1069
Practice Address - Country:US
Practice Address - Phone:907-561-1083
Practice Address - Fax:907-561-1075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDSDSMedicaid