Provider Demographics
NPI:1477743755
Name:EDGAR NOLLNER HEALTH CENTER
Entity Type:Organization
Organization Name:EDGAR NOLLNER HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:L
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-656-2489
Mailing Address - Street 1:PO BOX 77
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:AK
Mailing Address - Zip Code:99741-0077
Mailing Address - Country:US
Mailing Address - Phone:907-656-2366
Mailing Address - Fax:907-656-3122
Practice Address - Street 1:77 ANTOSKI
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:AK
Practice Address - Zip Code:99741-0077
Practice Address - Country:US
Practice Address - Phone:907-656-2366
Practice Address - Fax:907-656-3122
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF GALENA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-01
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearchGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCL4429Medicaid