Provider Demographics
NPI:1497731590
Name:ISC KETCHIKAN-JUNEAU DETACHMENT
Entity Type:Organization
Organization Name:ISC KETCHIKAN-JUNEAU DETACHMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF HEALTH SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:ESTEBAN
Authorized Official - Last Name:PALACIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-463-2140
Mailing Address - Street 1:709 W 9TH ST
Mailing Address - Street 2:USCG MEDICAL ROOM 627
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:709 W 9TH ST
Practice Address - Street 2:USCG MEDICAL ROOM 627
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1807
Practice Address - Country:US
Practice Address - Phone:907-463-2140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient