Healthcare Provider Details

I. General information

NPI: 1366573685
Provider Name (Legal Business Name): MANIILAQ ASSOCIATION KSCCC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 WOLVERINE DRIVE
KOTZEBUE AK
99752-1073
US

IV. Provider business mailing address

PO BOX 1073
KOTZEBUE AK
99752-1073
US

V. Phone/Fax

Practice location:
  • Phone: 907-442-7917
  • Fax: 907-442-7932
Mailing address:
  • Phone: 907-442-7917
  • Fax: 907-442-7932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number234051
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierCMG590
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: KELLIE B HAAS
Title or Position: ELDER SERVICES DIRECTOR
Credential: LPN
Phone: 907-442-7917