Basic Information
| Provider Information | |||||||||
| NPI: | 1922696038 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YUKON KUSKOKWIM HEALTH CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3427 | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995593427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436452 | ||||||||
| FaxNumber: | 9075436117 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 CHIEF EDDIE HOFFMAN HWY | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436452 | ||||||||
| FaxNumber: | 9075436117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2021 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | WILLARD | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9075436452 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.