Healthcare Provider Details

I. General information

NPI: 1295972677
Provider Name (Legal Business Name): KENAITZE INDIAN TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 UPLAND ST
KENAI AK
99611-8026
US

IV. Provider business mailing address

PO BOX 988
KENAI AK
99611-0988
US

V. Phone/Fax

Practice location:
  • Phone: 907-335-7500
  • Fax: 907-335-2155
Mailing address:
  • Phone: 907-335-7500
  • Fax: 907-335-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberIHS
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GREG BURNETT
Title or Position: FINANCE DIRECTOR
Credential:
Phone: 907-335-7200