Healthcare Provider Details

I. General information

NPI: 1780065227
Provider Name (Legal Business Name): ALASKA INNOVATIVE MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 06/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 B ST STE 200
ANCHORAGE AK
99503-5933
US

IV. Provider business mailing address

4300 B ST STE 200
ANCHORAGE AK
99503-5933
US

V. Phone/Fax

Practice location:
  • Phone: 907-229-8777
  • Fax:
Mailing address:
  • Phone: 907-229-8777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDTND156
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberNURR13740
License Number StateAK

VIII. Authorized Official

Name: KRISTI DAVIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 907-229-8777