Healthcare Provider Details

I. General information

NPI: 1003005828
Provider Name (Legal Business Name): MANIILAQ ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 SECOND AVE
KOTZEBUE AK
99752-0256
US

IV. Provider business mailing address

722 SECOND AVE
KOTZEBUE AK
99752-0256
US

V. Phone/Fax

Practice location:
  • Phone: 907-442-7640
  • Fax: 907-442-7822
Mailing address:
  • Phone: 907-442-7640
  • Fax: 907-442-7822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateAK

VIII. Authorized Official

Name: MR. ROCIO BAQUERIZO
Title or Position: DEPUTY DIRECTOR
Credential:
Phone: 907-442-7640