Healthcare Provider Details

I. General information

NPI: 1821074535
Provider Name (Legal Business Name): NATIVE VILLAGE OF EYAK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 09/14/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 2ND STREET
CORDOVA AK
99574
US

IV. Provider business mailing address

PO BOX 2290
CORDOVA AK
99574-2290
US

V. Phone/Fax

Practice location:
  • Phone: 907-424-3622
  • Fax: 907-424-3681
Mailing address:
  • Phone: 907-424-3622
  • Fax: 907-424-3275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number703435
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CINDY BRADFORD
Title or Position: OPERATIONS MANAGER
Credential: LNHA
Phone: 907-424-3622