=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780408054
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOREN S SIMEON
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2024
-----------------------------------------------------
Last Update Date | 11/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 CHIEF EDDIE HOFFMAN HWY
-----------------------------------------------------
City | BETHEL
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99559-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-543-6319
-----------------------------------------------------
Fax | 907-543-6117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3427
-----------------------------------------------------
City | BETHEL
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99559-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-543-6319
-----------------------------------------------------
Fax | 907-543-6117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number | 15-127-EFDHA
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------