Healthcare Provider Details

I. General information

NPI: 1487818639
Provider Name (Legal Business Name): CITY OF GALENA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 RUBY ROAD
RUBY AK
99768-0074
US

IV. Provider business mailing address

77 ANTOSKI AVENUE
GALENA AK
99741-0077
US

V. Phone/Fax

Practice location:
  • Phone: 907-468-4433
  • Fax: 907-468-4411
Mailing address:
  • Phone: 907-656-2366
  • Fax: 907-656-1525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VII. Legacy identifiers

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

# 1
IdentifierCL4429
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: CATHY ANNE DESANTO
Title or Position: EXECUTIVE DIRECTOR
Credential: ANP
Phone: 907-656-2366