Healthcare Provider Details

I. General information

NPI: 1497028526
Provider Name (Legal Business Name): PHILLIP D. COURTNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2012
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18708 SUE TAWN DRIVE
CHUGIAK AK
99567
US

IV. Provider business mailing address

PO BOX 670811
CHUGIAK AK
99567-0811
US

V. Phone/Fax

Practice location:
  • Phone: 907-688-0731
  • Fax:
Mailing address:
  • Phone: 907-688-0731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number24301
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: