Provider Demographics
NPI:1477847184
Name:CREEKSIDE FAMILY HEALTH CLINIC INC
Entity Type:Organization
Organization Name:CREEKSIDE FAMILY HEALTH CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-220-9982
Mailing Address - Street 1:3521 LOMITA BLVD
Mailing Address - Street 2:SUITE #103
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5039
Mailing Address - Country:US
Mailing Address - Phone:310-534-9131
Mailing Address - Fax:310-534-9132
Practice Address - Street 1:320 BAWDEN ST
Practice Address - Street 2:SUITE #313
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-6573
Practice Address - Country:US
Practice Address - Phone:907-220-9982
Practice Address - Fax:907-220-9972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-31
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMPG0359Medicaid
AKNP0504Medicaid
AKK161908Medicare PIN