Provider Demographics
NPI:1497957278
Name:MANIILAQ ASSOCIATION
Entity Type:Organization
Organization Name:MANIILAQ ASSOCIATION
Other - Org Name:MANIILAQ HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-442-3321
Mailing Address - Street 1:PO 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:907-442-3321
Mailing Address - Fax:907-442-7250
Practice Address - Street 1:436 5TH & TED STEVENS WAY
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752
Practice Address - Country:US
Practice Address - Phone:907-442-3321
Practice Address - Fax:907-442-7250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2340511223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDDG461Medicaid
AKDDG461Medicaid