Provider Demographics
NPI:1346585056
Name:YUKON-KUSKOKWIM HEALTH CORPORATION
Entity Type:Organization
Organization Name:YUKON-KUSKOKWIM HEALTH CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLLSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:907-543-6106
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:YUKON-KUSKOKWIM HEALTH CORPORATION
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-0528
Mailing Address - Country:US
Mailing Address - Phone:907-546-6106
Mailing Address - Fax:907-543-6159
Practice Address - Street 1:528 CHEIF EDDIE HOFFMEN
Practice Address - Street 2:YUKON-KUSKOKWIM HEALTH CORPORATION
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-0528
Practice Address - Country:US
Practice Address - Phone:907-546-6106
Practice Address - Fax:907-543-6159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKNUR R 27765261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health