Basic Information
| Provider Information | |||||||||
| NPI: | 1063840122 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANIILAQ ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 733 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997520256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074427640 | ||||||||
| FaxNumber: | 9074427749 | ||||||||
| Practice Location | |||||||||
| Address1: | 733 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997520256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074427640 | ||||||||
| FaxNumber: | 9074427749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2013 | ||||||||
| LastUpdateDate: | 10/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | COPPOCK | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
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| AuthorizedOfficialTitleorPosition: | CDCT | ||||||||
| AuthorizedOfficialTelephone: | 9074427640 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CDCI | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.