Healthcare Provider Details

I. General information

NPI: 1134258247
Provider Name (Legal Business Name): OLGA IRIS WASILE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20905 EASTSIDE DR #1
CHUGIAK AK
99567-1249
US

IV. Provider business mailing address

PO BOX 671249
CHUGIAK AK
99567-1249
US

V. Phone/Fax

Practice location:
  • Phone: 907-688-0901
  • Fax: 907-688-0830
Mailing address:
  • Phone: 907-688-0901
  • Fax: 907-688-0830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIANE E HODGES
Title or Position: OFFICE MANAGER
Credential:
Phone: 907-688-0901