Provider Demographics
NPI:1285019869
Name:FAIRBANKS FAMILY WELLNESS,LLC
Entity Type:Organization
Organization Name:FAIRBANKS FAMILY WELLNESS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:FALCONER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-479-2331
Mailing Address - Street 1:3550 AIRPORT WAY #4
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709
Mailing Address - Country:US
Mailing Address - Phone:907-479-2331
Mailing Address - Fax:
Practice Address - Street 1:3550 AIRPORT WAY STE 4
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4772
Practice Address - Country:US
Practice Address - Phone:907-479-2306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-24
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK596111N00000X
AK152171100000X
AK40175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK=========OtherPREMERA BLUE CROSS BLUE SHIELD