Healthcare Provider Details

I. General information

NPI: 1285948877
Provider Name (Legal Business Name): HSWL FO KODIAK DET KETCHIKAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 STEDMAN ST
KETCHIKAN AK
99901-6661
US

IV. Provider business mailing address

1300 STEDMAN ST
KETCHIKAN AK
99901-6661
US

V. Phone/Fax

Practice location:
  • Phone: 907-228-0320
  • Fax: 907-228-0255
Mailing address:
  • Phone: 907-228-0320
  • Fax: 907-228-0255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ROBERT BIDWELL
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 907-228-0320