Basic Information
| Provider Information | |||||||||
| NPI: | 1386817237 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRBANKS NATIVE ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRAF RHEENEERHAANJII | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 WENDELL AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074526251 | ||||||||
| FaxNumber: | 9074521001 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 LAWLOR RD | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997096458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074554725 | ||||||||
| FaxNumber: | 9074554730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2008 | ||||||||
| LastUpdateDate: | 11/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | ASHOGEAK | ||||||||
| AuthorizedOfficialFirstName: | PERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BEHAVIORAL HEALTH DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9074526251 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 1696801 | 05 | AK | MEDICAID |