Provider Demographics
NPI:1629233416
Name:MANIILAQ ASSOCIATION
Entity Type:Organization
Organization Name:MANIILAQ ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ELDER SERVICES DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:HAAS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:907-442-7917
Mailing Address - Street 1:607 WOLVERINE DRIVE
Mailing Address - Street 2:BOX 1073
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:BOX 1073
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:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKHC3590251E00000X, 332U00000X, 343900000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No332U00000XSuppliersHome Delivered Meals
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHC3590Medicaid
AKHC3590OtherDSDS CERTIFICATION