Basic Information
| Provider Information | |||||||||
| NPI: | 1780705608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MANIILAQ ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 256 | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997520256 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 733 SECOND AVE | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997520256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074427640 | ||||||||
| FaxNumber: | 9074427822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 08/08/2007 | ||||||||
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| AuthorizedOfficialLastName: | BOLEN | ||||||||
| AuthorizedOfficialFirstName: | HELEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9074423311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 241 | AK | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.