Provider Demographics
NPI:1063668861
Name:FAIRBANKS NORTHSTAR BOROUGH VAN TRAN
Entity Type:Organization
Organization Name:FAIRBANKS NORTHSTAR BOROUGH VAN TRAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRANSPORTATION DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-459-1007
Mailing Address - Street 1:3175 PEGER RD
Mailing Address - Street 2:ATTN: VAN TRAN
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-5454
Mailing Address - Country:US
Mailing Address - Phone:907-459-1010
Mailing Address - Fax:907-459-7908
Practice Address - Street 1:501 CUSHMAN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4633
Practice Address - Country:US
Practice Address - Phone:907-459-1010
Practice Address - Fax:907-459-7908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHC3175Medicaid