Basic Information
| Provider Information | |||||||||
| NPI: | 1548464472 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANIILAQ ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MANIILAQ HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43 | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997520043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074423321 | ||||||||
| FaxNumber: | 9074427250 | ||||||||
| Practice Location | |||||||||
| Address1: | 436 5TH & TED STEVENS WAY | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074423321 | ||||||||
| FaxNumber: | 9074427250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HANSON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9074423321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3747P1801X | 234051 | AK | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Related Providers | Technician | Personal Care Attendant |
ID Information
| ID | Type | State | Issuer | Description | PCG461 | 05 | AK | MEDICAID |