Basic Information
Provider Information | |||||||||
NPI: | 1154594216 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAIRBANKS NATIVE ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RALPH PERDUE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 605 HUGHES AVE | ||||||||
Address2: |   | ||||||||
City: | FAIRBANKS | ||||||||
State: | AK | ||||||||
PostalCode: | 997017539 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9074521648 | ||||||||
FaxNumber: | 9074564849 | ||||||||
Practice Location | |||||||||
Address1: | 3100 S CUSHMAN ST | ||||||||
Address2: |   | ||||||||
City: | FAIRBANKS | ||||||||
State: | AK | ||||||||
PostalCode: | 997017516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9074526251 | ||||||||
FaxNumber: | 9074564849 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2008 | ||||||||
LastUpdateDate: | 04/10/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PATTERSON | ||||||||
AuthorizedOfficialFirstName: | GUY | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | BHS DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9074526251 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 76821 | AK | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   |
ID Information
ID | Type | State | Issuer | Description | DA4435 | 05 | AK |   | MEDICAID |