Healthcare Provider Details

I. General information

NPI: 1720064884
Provider Name (Legal Business Name): INTEGRATED SUPPORT COMMAND KODIAK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING N46 CAPE SARICHEF
KODIAK AK
99619-5002
US

IV. Provider business mailing address

BUILDING N 46 CAPE SARLCHEF
KODIAK AK
99619-5002
US

V. Phone/Fax

Practice location:
  • Phone: 907-487-5757
  • Fax: 907-487-5360
Mailing address:
  • Phone: 907-487-5757
  • Fax: 907-487-5360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code291900000X
TaxonomyMilitary Clinical Medical Laboratory
License Number02D0666660
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License NumberNCPDP0202414
License Number StateAK

VIII. Authorized Official

Name: TODD LANE EMERSON
Title or Position: CLINIC ADMINISTRATOR
Credential: CLINIC ADMINISTRATOR
Phone: 907-487-5757