Healthcare Provider Details

I. General information

NPI: 1578956041
Provider Name (Legal Business Name): GUNNAR WULVIK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 4TH AVE
BETHEL AK
99559
US

IV. Provider business mailing address

PO BOX 3227 ATTN: BH BAUTISTA HOUSE PROGRAM
BETHEL AK
99559-3227
US

V. Phone/Fax

Practice location:
  • Phone: 907-543-2242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: