Provider Demographics
NPI:1518472984
Name:MAT-SU VALLEY III LLC
Entity Type:Organization
Organization Name:MAT-SU VALLEY III LLC
Other - Org Name:MAT SU URGENT CARE - PALMER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-465-7042
Mailing Address - Fax:615-628-6877
Practice Address - Street 1:209 W EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6952
Practice Address - Country:US
Practice Address - Phone:907-861-1400
Practice Address - Fax:907-861-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-07
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPENDINGMedicaid