Healthcare Provider Details

I. General information

NPI: 1629233416
Provider Name (Legal Business Name): MANIILAQ ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 WOLVERINE DRIVE BOX 1073
KOTZEBUE AK
99752-1073
US

IV. Provider business mailing address

607 WOLVERINE DRIVE 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 Code251E00000X
TaxonomyHome Health Agency
License NumberHC3590
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License NumberHC3590
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberHC3590
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberHC3590
License Number StateAK

VIII. Authorized Official

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