Basic Information
| Provider Information | |||||||||
| NPI: | 1376520692 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILIULIUK FAMILY AND HEALTH SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 144 | ||||||||
| Address2: | |||||||||
| City: | UNALASKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996850144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075811202 | ||||||||
| FaxNumber: | 9075812331 | ||||||||
| Practice Location | |||||||||
| Address1: | 34 LAVELLE COURT | ||||||||
| Address2: | |||||||||
| City: | UNALASKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996850144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075812331 | ||||||||
| FaxNumber: | 9075812331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 10/31/2018 | ||||||||
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| AuthorizedOfficialLastName: | KAECH | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9075818658 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 147861 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 122300000X | 147861 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 363A00000X | 147861 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | RH522FQ | 05 | AK | MEDICAID |