Basic Information
| Provider Information | |||||||||
| NPI: | 1467679936 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YUKON-KUSKOKWIM HEALTH CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 528 | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5016 NOEL POLTY BLVD. | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436800 | ||||||||
| FaxNumber: | 9075437101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 07/31/2013 | ||||||||
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| AuthorizedOfficialLastName: | PELTOLA | ||||||||
| AuthorizedOfficialFirstName: | EUGENE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 9075436020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 323P00000X | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | HS414PI | 05 | AK | MEDICAID |