Healthcare Provider Details

I. General information

NPI: 1477156859
Provider Name (Legal Business Name): MARY ANN GATES LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 MILL BAY RD STE B
KODIAK AK
99615-6485
US

IV. Provider business mailing address

PO BOX 1291
KODIAK AK
99615-1291
US

V. Phone/Fax

Practice location:
  • Phone: 907-512-5411
  • Fax: 833-641-2568
Mailing address:
  • Phone: 971-235-0680
  • Fax: 833-641-2568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number201318
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: