Provider Demographics
NPI:1609093723
Name:NINILCHIK VILLAGE TRIBAL COUNCIL
Entity Type:Organization
Organization Name:NINILCHIK VILLAGE TRIBAL COUNCIL
Other - Org Name:NINILCHIK COMMUNITY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:ZANE
Authorized Official - Last Name:ENCELEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-567-3313
Mailing Address - Street 1:PO BOX 39368
Mailing Address - Street 2:
Mailing Address - City:NINILCHIK
Mailing Address - State:AK
Mailing Address - Zip Code:99639-0368
Mailing Address - Country:US
Mailing Address - Phone:907-567-3970
Mailing Address - Fax:907-567-3948
Practice Address - Street 1:15765 KINGSLEY ROAD
Practice Address - Street 2:
Practice Address - City:NINILCHIK
Practice Address - State:AK
Practice Address - Zip Code:99639-9759
Practice Address - Country:US
Practice Address - Phone:907-567-3970
Practice Address - Fax:907-567-3948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK296082261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCL 2699Medicaid