Provider Demographics
NPI:1003005828
Name:MANIILAQ ASSOCIATION
Entity Type:Organization
Organization Name:MANIILAQ ASSOCIATION
Other - Org Name:MANIILAQ RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROCIO
Authorized Official - Middle Name:
Authorized Official - Last Name:BAQUERIZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-442-7640
Mailing Address - Street 1:722 SECOND AVE
Mailing Address - Street 2:
Mailing Address - City:KOTZEBUE
Mailing Address - State:AK
Mailing Address - Zip Code:99752-0256
Mailing Address - Country:US
Mailing Address - Phone:907-442-7640
Mailing Address - Fax:907-442-7822
Practice Address - Street 1:722 SECOND AVE
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752-0256
Practice Address - Country:US
Practice Address - Phone:907-442-7640
Practice Address - Fax:907-442-7822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
324500000X
AK324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility