Basic Information
| Provider Information | |||||||||
| NPI: | 1710126008 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH EAST ALASKA REGIONAL HEALTH CONSORTIUM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SHORT TERM HOUSING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 CHANNEL DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074634074 | ||||||||
| FaxNumber: | 9074631510 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 TONGASS DR BLDG 121 | ||||||||
| Address2: | |||||||||
| City: | SITKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998359416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079662411 | ||||||||
| FaxNumber: | 9079668606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2009 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 9074634000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 177F00000X | 70206 | AK | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Lodging |
ID Information
| ID | Type | State | Issuer | Description | 1659301 | 05 | AK | MEDICAID |