Basic Information
| Provider Information | |||||||||
| NPI: | 1578736211 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRBANKS NATIVE ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WOMEN AND CHILDREN'S CENTER FOR INNER HEALING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 315 WENDELL AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074526251 | ||||||||
| FaxNumber: | 9074521001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 EVERGREEN ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997094306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074518164 | ||||||||
| FaxNumber: | 9074564849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2008 | ||||||||
| LastUpdateDate: | 11/08/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AHSOGEAK | ||||||||
| AuthorizedOfficialFirstName: | PERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BHS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9074526251 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
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 | 1696805 | 05 | AK | MEDICAID |