Basic Information
| Provider Information | |||||||||
| NPI: | 1255478806 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANIILAQ ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SHUNGNAK HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 32 BACK STREET | ||||||||
| Address2: | |||||||||
| City: | SHUNGNAK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997730080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074372138 | ||||||||
| FaxNumber: | 9074372139 | ||||||||
| Practice Location | |||||||||
| Address1: | 32 BACK STREET | ||||||||
| Address2: | |||||||||
| City: | SHUNGNAK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997730080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074372138 | ||||||||
| FaxNumber: | 9074372139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TICKETT | ||||||||
| AuthorizedOfficialFirstName: | CHARLENE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHP | ||||||||
| AuthorizedOfficialTelephone: | 9074372138 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | AK | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.