Healthcare Provider Details

I. General information

NPI: 1861935975
Provider Name (Legal Business Name): MAT-SU VALLEY III LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2016
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5851 SOUTH KNIK-GOOSE BAY ROAD
WASILLA AK
99623
US

IV. Provider business mailing address

PO BOX 689022
FRANKLIN TN
37068-9022
US

V. Phone/Fax

Practice location:
  • Phone: 907-864-1300
  • Fax: 907-864-1305
Mailing address:
  • Phone: 615-465-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateAK

VIII. Authorized Official

Name: KRISTY MUSIC
Title or Position: DIRECTOR, PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7377