Provider Demographics
NPI:1124593512
Name:CALM HARBOR HEALTH CLINIC
Entity Type:Organization
Organization Name:CALM HARBOR HEALTH CLINIC
Other - Org Name:CALM HARBOR HEALTH CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:JUDITH-ROWE
Authorized Official - Last Name:MCINTYRE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:907-617-4481
Mailing Address - Street 1:3528 TONGASS AVE
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5635
Mailing Address - Country:US
Mailing Address - Phone:907-617-4481
Mailing Address - Fax:
Practice Address - Street 1:3528 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5635
Practice Address - Country:US
Practice Address - Phone:907-617-4481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-11
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1612171Medicaid