Provider Demographics
NPI:1073081485
Name:TANANA VALLEY CLINIC LLC
Entity Type:Organization
Organization Name:TANANA VALLEY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-458-3310
Mailing Address - Street 1:PO BOX 73720
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3720
Mailing Address - Country:US
Mailing Address - Phone:907-459-3500
Mailing Address - Fax:
Practice Address - Street 1:570 RIVERSTONE WAY
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-2940
Practice Address - Country:US
Practice Address - Phone:907-459-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUNDATION HEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1656221Medicaid