Healthcare Provider Details

I. General information

NPI: 1255528733
Provider Name (Legal Business Name): KENAI FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 BIDARKA ST SUITE 101
KENAI AK
99611-7741
US

IV. Provider business mailing address

135 BIDARKA ST SUITE 101
KENAI AK
99611-7741
US

V. Phone/Fax

Practice location:
  • Phone: 907-335-0034
  • Fax: 907-335-0064
Mailing address:
  • Phone: 907-335-0034
  • Fax: 907-335-0064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4040
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number725
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number175
License Number StateAK

VIII. Authorized Official

Name: DR. TERRI L ELLIOTT
Title or Position: OWNER
Credential: D.O.
Phone: 907-335-0034