Provider Demographics
NPI:1205372885
Name:SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM
Entity Type:Organization
Organization Name:SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM
Other - Org Name:SEARHC AICS DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:VP/CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-463-4000
Mailing Address - Street 1:3100 CHANNEL DRIVE STE 300
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801
Mailing Address - Country:US
Mailing Address - Phone:907-463-4000
Mailing Address - Fax:907-463-1510
Practice Address - Street 1:215 FRONT ST
Practice Address - Street 2:
Practice Address - City:WRANGELL
Practice Address - State:AK
Practice Address - Zip Code:99929
Practice Address - Country:US
Practice Address - Phone:907-874-3731
Practice Address - Fax:907-874-3531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-06
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1663271Medicaid
AK70206OtherBUSINESS LICENSE