Healthcare Provider Details

I. General information

NPI: 1740531656
Provider Name (Legal Business Name): TANANA CHIEFS CONFERENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 1ST AVE STE 600
FAIRBANKS AK
99701-4871
US

IV. Provider business mailing address

122 1ST AVE STE 600
FAIRBANKS AK
99701-4871
US

V. Phone/Fax

Practice location:
  • Phone: 907-452-8251
  • Fax:
Mailing address:
  • Phone: 907-452-8251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateAK

VIII. Authorized Official

Name: JERRY ISSAC
Title or Position: CEO
Credential:
Phone: 907-452-8251