Healthcare Provider Details

I. General information

NPI: 1255478806
Provider Name (Legal Business Name): MANIILAQ ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 BACK STREET
SHUNGNAK AK
99773-0080
US

IV. Provider business mailing address

32 BACK STREET
SHUNGNAK AK
99773-0080
US

V. Phone/Fax

Practice location:
  • Phone: 907-437-2138
  • Fax: 907-437-2139
Mailing address:
  • Phone: 907-437-2138
  • Fax: 907-437-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateAK

VIII. Authorized Official

Name: CHARLENE D TICKETT
Title or Position: CHP
Credential:
Phone: 907-437-2138