Healthcare Provider Details

I. General information

NPI: 1093461667
Provider Name (Legal Business Name): MANIILAQ ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 03/15/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1729 QALGI AVE
POINT HOPE AK
99766
US

IV. Provider business mailing address

PO BOX 43
KOTZEBUE AK
99752-0043
US

V. Phone/Fax

Practice location:
  • Phone: 907-442-3321
  • Fax: 907-442-7250
Mailing address:
  • Phone: 907-442-3321
  • Fax: 907-442-7250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GUS NELSON
Title or Position: PROVIDER ENROLLMENT SPECIALIST
Credential:
Phone: 907-442-3321