Provider Demographics
NPI:1043417959
Name:TOK CLINIC, LLC
Entity Type:Organization
Organization Name:TOK CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:907-883-5855
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:TOK
Mailing Address - State:AK
Mailing Address - Zip Code:99780-0289
Mailing Address - Country:US
Mailing Address - Phone:907-883-5855
Mailing Address - Fax:907-883-1043
Practice Address - Street 1:MILE 124.5 TOK CUTOFF
Practice Address - Street 2:
Practice Address - City:TOK
Practice Address - State:AK
Practice Address - Zip Code:99780-0289
Practice Address - Country:US
Practice Address - Phone:907-883-5855
Practice Address - Fax:907-883-1043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA 2011207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD 25592Medicaid
AKK0000WFBMVMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER