Provider Demographics
NPI:1629109939
Name:MANIILAQ ASSOCIATION KSCCC
Entity Type:Organization
Organization Name:MANIILAQ ASSOCIATION KSCCC
Other - Org Name:KOTZEBUE SENIOR CITIZENS CULTURAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ELDER SERVICES DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:HAAS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:907-442-7917
Mailing Address - Street 1:PO BOX 1073
Mailing Address - Street 2:
Mailing Address - City:KOTZEBUE
Mailing Address - State:AK
Mailing Address - Zip Code:99752-1073
Mailing Address - Country:US
Mailing Address - Phone:907-442-7917
Mailing Address - Fax:907-442-7932
Practice Address - Street 1:607 WOLVERINE DRIVE
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752-1073
Practice Address - Country:US
Practice Address - Phone:907-442-7917
Practice Address - Fax:907-442-7932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK000063310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL3590Medicaid
AKCMG590Medicaid