Provider Demographics
NPI:1033437132
Name:NINAK INC.
Entity Type:Organization
Organization Name:NINAK INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PRACTICE
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:307-203-9239
Mailing Address - Street 1:23371 MULHOLLAND DR
Mailing Address - Street 2:STE 327
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-2734
Mailing Address - Country:US
Mailing Address - Phone:307-203-9239
Mailing Address - Fax:877-332-9683
Practice Address - Street 1:170 E BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:82001-9906
Practice Address - Country:US
Practice Address - Phone:307-203-9239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6084A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY6084AMedicare PIN