MEDICARE: CHICKALOON NATIVE VILLLAGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QC1500X	Community Health Clinic/Center		AK

General Provider Information

NPI Number	:	1619267937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICKALOON NATIVE VILLLAGE

Provider Business Mailing Address
First Line	:	PO BOX 1105
Second Line	:
City	:	CHICKALOON
State	:	AK
Zip	:	99674-1105
Country	:	US
Telephone Number	:	907-745-0704
Fax Number	:	907-745-0708

Provider Business Practice Location Address
First Line	:	16166 NORTH GLEN HIGHWAY
Second Line	:	MILE 61.5 GLEN HIGHWAY
City	:	SUTTON
State	:	AK
Zip	:	99674-1105
Country	:	US
Telephone Number	:	907-745-0704
Fax Number	:	907-745-0708

Authorized Official
Title or Position	:	CLINIC MANAGER
Name	:	MRS. AMANDA NICOLE CHRISTIANSEN
Credential	:
Telephone Number	:	907-745-0704

Provider Enumeration Date	:	04/08/2011
Last Update Date	:	04/08/2011

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