Basic Information
| Provider Information | |||||||||
| NPI: | 1013551456 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL NETWORK OF ALASKA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CAPSTONE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3122 E MERIDIAN PARK LOOP | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996547255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073579590 | ||||||||
| FaxNumber: | 9073579593 | ||||||||
| Practice Location | |||||||||
| Address1: | 10543 KENAI SPUR HWY | ||||||||
| Address2: | |||||||||
| City: | KENAI | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996117812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073579590 | ||||||||
| FaxNumber: | 9073579593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2019 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLOMKER | ||||||||
| AuthorizedOfficialFirstName: | JACQUELYN | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | RCM | ||||||||
| AuthorizedOfficialTelephone: | 9078644625 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAPSTONE FAMILY MEDICINE, LLC | ||||||||
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| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.