Basic Information
| Provider Information | |||||||||
| NPI: | 1508401381 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRBANKS NATIVE ASSOCIATION | ||||||||
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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: | 3100 S CUSHMAN ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997017516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074526251 | ||||||||
| FaxNumber: | 9074564849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2019 | ||||||||
| LastUpdateDate: | 11/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | AHSOGEAK | ||||||||
| AuthorizedOfficialFirstName: | PERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BEHAVIORAL HEALTH DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9074526251 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 1696809 | 05 | AK | MEDICAID |