Provider Demographics
NPI:1619267937
Name:CHICKALOON NATIVE VILLLAGE
Entity Type:Organization
Organization Name:CHICKALOON NATIVE VILLLAGE
Other - Org Name:CHICKALOON VILLAGE TRADITIONAL COUNCIL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:CHRISTIANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-745-0704
Mailing Address - Street 1:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:CHICKALOON
Mailing Address - State:AK
Mailing Address - Zip Code:99674-1105
Mailing Address - Country:US
Mailing Address - Phone:907-745-0704
Mailing Address - Fax:907-745-0708
Practice Address - Street 1:16166 NORTH GLEN HIGHWAY
Practice Address - Street 2:MILE 61.5 GLEN HIGHWAY
Practice Address - City:SUTTON
Practice Address - State:AK
Practice Address - Zip Code:99674-1105
Practice Address - Country:US
Practice Address - Phone:907-745-0704
Practice Address - Fax:907-745-0708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health