Provider Demographics
NPI:1437378189
Name:MT SANFORD TRIBAL CONSORTIUM
Entity Type:Organization
Organization Name:MT SANFORD TRIBAL CONSORTIUM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAP CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DRINKWATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-822-5399
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:GAKONA
Mailing Address - State:AK
Mailing Address - Zip Code:99586-0357
Mailing Address - Country:US
Mailing Address - Phone:907-822-5399
Mailing Address - Fax:907-822-5810
Practice Address - Street 1:MILE 7 MENTASTA ROAD
Practice Address - Street 2:
Practice Address - City:MENTASTA
Practice Address - State:AK
Practice Address - Zip Code:99780
Practice Address - Country:US
Practice Address - Phone:907-291-2320
Practice Address - Fax:907-291-2308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCL3492Medicaid