Provider Demographics
NPI:1083125355
Name:KODIAK LIFE DIAGNOSTIC IMAGING, INC
Entity Type:Organization
Organization Name:KODIAK LIFE DIAGNOSTIC IMAGING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DARRYL
Authorized Official - Last Name:BISE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:907-512-9559
Mailing Address - Street 1:PO BOX 8790
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-8790
Mailing Address - Country:US
Mailing Address - Phone:907-512-9559
Mailing Address - Fax:
Practice Address - Street 1:1915 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6602
Practice Address - Country:US
Practice Address - Phone:907-512-9559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK106389261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology