Basic Information
Provider Information | |||||||||
NPI: | 1134765290 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SEARHC WRANGELL BEHAVIORAL HEALTH-1115 WAIVER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3100 CHANNEL DR STE 300 | ||||||||
Address2: |   | ||||||||
City: | JUNEAU | ||||||||
State: | AK | ||||||||
PostalCode: | 998017837 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9074634074 | ||||||||
FaxNumber: | 9074631510 | ||||||||
Practice Location | |||||||||
Address1: | 333 CHURCH STREET | ||||||||
Address2: |   | ||||||||
City: | WRANGELL | ||||||||
State: | AK | ||||||||
PostalCode: | 99929 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9078742373 | ||||||||
FaxNumber: | 9078742576 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/25/2019 | ||||||||
LastUpdateDate: | 02/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARRIS | ||||||||
AuthorizedOfficialFirstName: | DANIEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
AuthorizedOfficialTelephone: | 9074634000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 1704809 | 05 | AK |   | MEDICAID | 70206 | 01 | AK | STATE OF ALASKA | OTHER |