Basic Information
Provider Information | |||||||||
NPI: | 1326262726 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | YUKON KUSKOKWIM HEALTH CORP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 528 | ||||||||
Address2: |   | ||||||||
City: | BETHEL | ||||||||
State: | AK | ||||||||
PostalCode: | 995590528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075436000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 829 CHIEF EDDIE HOFFMAN HWY | ||||||||
Address2: | STE 340 | ||||||||
City: | BETHEL | ||||||||
State: | AK | ||||||||
PostalCode: | 99559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075436000 | ||||||||
FaxNumber: | 9075436117 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2007 | ||||||||
LastUpdateDate: | 03/03/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PELTOLA | ||||||||
AuthorizedOfficialFirstName: | GENE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9075436020 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   | 126800000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Assistant |   | 1223G0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | DDG141 | 05 | AK |   | MEDICAID |