Provider Demographics
NPI:1376810937
Name:MANIILAQ ASSOCIATION
Entity Type:Organization
Organization Name:MANIILAQ ASSOCIATION
Other - Org Name:SHUNGNAK CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-442-7150
Mailing Address - Street 1:P.O. BOX 43
Mailing Address - Street 2:
Mailing Address - City:KOTZEBUE
Mailing Address - State:AK
Mailing Address - Zip Code:99752-0043
Mailing Address - Country:US
Mailing Address - Phone:907-442-7150
Mailing Address - Fax:907-442-7250
Practice Address - Street 1:80 BACK ST.
Practice Address - Street 2:
Practice Address - City:SHUNGNAK
Practice Address - State:AK
Practice Address - Zip Code:99773-0080
Practice Address - Country:US
Practice Address - Phone:907-437-2138
Practice Address - Fax:907-437-2139
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MANIILAQ ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK021310Medicare Oscar/Certification
AKTEZ042Medicare PIN