Healthcare Provider Details

I. General information

NPI: 1083657712
Provider Name (Legal Business Name): GIRDWOOD CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LOT 17 BLOCK 1 NEW GIRDWOOD TOWN SITE
GIRDWOOD AK
99587
US

IV. Provider business mailing address

PO BOX 1130
GIRDWOOD AK
99587-1130
US

V. Phone/Fax

Practice location:
  • Phone: 907-783-1355
  • Fax: 907-783-1357
Mailing address:
  • Phone: 907-783-1355
  • Fax: 907-783-1357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KERRY L DORIUS
Title or Position: PRESIDENT
Credential: ANP
Phone: 907-783-1355