Basic Information
| Provider Information | |||||||||
| NPI: | 1699392258 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MANIILAQ ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43 | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997520043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074427238 | ||||||||
| FaxNumber: | 9074427403 | ||||||||
| Practice Location | |||||||||
| Address1: | 733 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074427238 | ||||||||
| FaxNumber: | 9074427403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2020 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | JACOBS | ||||||||
| AuthorizedOfficialFirstName: | ERIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PATIENT FINANCIAL SERVI | ||||||||
| AuthorizedOfficialTelephone: | 9074427238 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1021015 | 05 | AK | MEDICAID |