Healthcare Provider Details

I. General information

NPI: 1396897419
Provider Name (Legal Business Name): COOK INLET COUNCIL ON ALCOHOL AND DRUG ABUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 KENAI SPUR HWY
KENAI AK
99611-7807
US

IV. Provider business mailing address

10200 KENAI SPUR HWY
KENAI AK
99611-7807
US

V. Phone/Fax

Practice location:
  • Phone: 907-283-3658
  • Fax: 907-283-5046
Mailing address:
  • Phone: 907-283-3658
  • Fax: 907-283-5046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateAK

VIII. Authorized Official

Name: HENRY KRISTOFOR NOVAK
Title or Position: EXECUTIVE DIRECTOR
Credential: B.S.
Phone: 907-283-3658