Healthcare Provider Details

I. General information

NPI: 1003352402
Provider Name (Legal Business Name): SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 01/20/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LYNCH STREET
WRANGELL AK
99929
US

IV. Provider business mailing address

3100 CHANNEL DRIVE STE 300 ATTN: PROVIDER ENROLLMENT
JUNEAU AK
99801
US

V. Phone/Fax

Practice location:
  • Phone: 907-874-3375
  • Fax:
Mailing address:
  • Phone: 907-463-4000
  • Fax: 907-463-1510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1666511
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 2
Identifier70206
Identifier TypeOTHER
Identifier StateAK
Identifier IssuerBUSINESS LICENSE
# 3
Identifier1674341
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: MR. DANIEL HARRIS
Title or Position: VP/CHIEF FINANCIAL OFFICER
Credential:
Phone: 907-463-4000