=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548293798
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHCENTRAL FOUNDATION NIKOLAI HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 01/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9105 AIRPORT DRIVE
-----------------------------------------------------
City | NIKOLAI
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-293-2328
-----------------------------------------------------
Fax | 907-729-6353
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4201 TUDOR CENTRE DR STE 320
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99508-5916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-729-4955
-----------------------------------------------------
Fax | 907-729-6353
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PATIENT ACCOUNTS
-----------------------------------------------------
Name | CATHY A LEMAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 907-729-4955
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------