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General NPI Number Information
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NPI Number | 1043966567
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Entity Type | Organization
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Legal Business Name | MANIILAQ ASSOCIATION
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Dates
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Enumeration Date | 02/23/2022
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Last Update Date | 03/15/2022
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Provider Practice Location Address
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Address Line | 9 HILLSIDE RD
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City | BUCKLAND
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State | AK
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Zip | 99727
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Country | US
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Telephone | 907-442-3321
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Fax | 907-442-7250
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Provider Business Mailing Address
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Address Line | PO BOX 43
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City | KOTZEBUE
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State | AK
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Zip | 99752-0043
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Country | US
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Telephone | 907-442-3321
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Fax | 907-442-7250
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Authorized Official
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Title or Position | PROVIDER ENROLLMENT SPECIALIST
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Name | GUS NELSON
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Credential |
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Telephone | 907-442-3321
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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