Provider Demographics
NPI:1508286857
Name:MT. SANFORD TRIBAL CONSORTIUM
Entity Type:Organization
Organization Name:MT. SANFORD TRIBAL CONSORTIUM
Other - Org Name:MENTASTA CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BEATY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-770-2380
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:
Mailing Address - Fax:
Practice Address - Street 1:MILE 7 MENTASTA ROAD
Practice Address - Street 2:
Practice Address - City:MENTASTA
Practice Address - State:AK
Practice Address - Zip Code:99780-9803
Practice Address - Country:US
Practice Address - Phone:907-822-5399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty