Basic Information
| Provider Information | |||||||||
| NPI: | 1659583383 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YUKON KUSKOKWIM HEALTH CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 829 CHIEF EDDIE HOFFMAN HWY. | ||||||||
| Address2: | SUITE BOX 528 | ||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436300 | ||||||||
| FaxNumber: | 9075436926 | ||||||||
| Practice Location | |||||||||
| Address1: | 829 CHIEF EDDIE HOFFMAN HWY. | ||||||||
| Address2: | STE 340 | ||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436000 | ||||||||
| FaxNumber: | 9075436117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 03/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | PELTOLA | ||||||||
| AuthorizedOfficialFirstName: | GENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9075436020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | CL1414 | 05 | AK | MEDICAID |