Basic Information
| Provider Information | |||||||||
| NPI: | 1003005828 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANIILAQ ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MANIILAQ RECOVERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 722 SECOND AVE | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997520256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074427640 | ||||||||
| FaxNumber: | 9074427822 | ||||||||
| Practice Location | |||||||||
| Address1: | 722 SECOND AVE | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997520256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074427640 | ||||||||
| FaxNumber: | 9074427822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2007 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAQUERIZO | ||||||||
| AuthorizedOfficialFirstName: | ROCIO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9074427640 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 324500000X | AK | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.