Basic Information
Provider Information | |||||||||
NPI: | 1700057676 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHUGACHMIUT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ARCH PRIEST NICHOLAS KOMPKOFF CLINIC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1840 BRAGAW ST STE 110 | ||||||||
Address2: |   | ||||||||
City: | ANCHORAGE | ||||||||
State: | AK | ||||||||
PostalCode: | 995083463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075624155 | ||||||||
FaxNumber: | 9075632891 | ||||||||
Practice Location | |||||||||
Address1: | 625 MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | CHENEGA | ||||||||
State: | AK | ||||||||
PostalCode: | 995748029 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075735129 | ||||||||
FaxNumber: | 9075735148 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/18/2008 | ||||||||
LastUpdateDate: | 12/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BAKER | ||||||||
AuthorizedOfficialFirstName: | KELLEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | HEALTH SERVICES DIVISION DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9075624155 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/14/2021 |
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 | 1021383 | 05 | AK |   | MEDICAID |