Provider Demographics
NPI:1063840122
Name:MANIILAQ ASSOCIATION
Entity Type:Organization
Organization Name:MANIILAQ ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CDCT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:COPPOCK
Authorized Official - Suffix:
Authorized Official - Credentials:CDCI
Authorized Official - Phone:907-442-7640
Mailing Address - Street 1:733 2ND 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:907-442-7749
Practice Address - Street 1:733 2ND 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:907-442-7749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health