=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720064884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED SUPPORT COMMAND KODIAK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2005
-----------------------------------------------------
Last Update Date | 07/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | BUILDING N46 CAPE SARICHEF
-----------------------------------------------------
City | KODIAK
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99619-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-487-5757
-----------------------------------------------------
Fax | 907-487-5360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | BUILDING N 46 CAPE SARLCHEF
-----------------------------------------------------
City | KODIAK
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99619-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-487-5757
-----------------------------------------------------
Fax | 907-487-5360
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC ADMINISTRATOR
-----------------------------------------------------
Name | TODD LANE EMERSON
-----------------------------------------------------
Credential | CLINIC ADMINISTRATOR
-----------------------------------------------------
Telephone | 907-487-5757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 291900000X
-----------------------------------------------------
Taxonomy Name | Military Clinical Medical Laboratory
-----------------------------------------------------
License Number | 02D0666660
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332000000X
-----------------------------------------------------
Taxonomy Name | Military/U.S. Coast Guard Pharmacy
-----------------------------------------------------
License Number | NCPDP0202414
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------