Provider Demographics
NPI:1508401381
Name:FAIRBANKS NATIVE ASSOCIATION
Entity Type:Organization
Organization Name:FAIRBANKS NATIVE ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:AHSOGEAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-452-6251
Mailing Address - Street 1:315 WENDELL AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4837
Mailing Address - Country:US
Mailing Address - Phone:907-452-6251
Mailing Address - Fax:907-452-1001
Practice Address - Street 1:3100 S CUSHMAN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7516
Practice Address - Country:US
Practice Address - Phone:907-452-6251
Practice Address - Fax:907-456-4849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1696809Medicaid