Basic Information
| Provider Information | |||||||||
| NPI: | 1508912668 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALASKA ISLAND COMMUNITY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1231 | ||||||||
| Address2: | |||||||||
| City: | WRANGELL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999291231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078744700 | ||||||||
| FaxNumber: | 9078744719 | ||||||||
| Practice Location | |||||||||
| Address1: | SUNRISE LODGE | ||||||||
| Address2: | |||||||||
| City: | EDNA BAY | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078744700 | ||||||||
| FaxNumber: | 9078744719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 07/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9078744700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | RH545FQ | 05 | AK | MEDICAID |