Provider Demographics
NPI:1629298120
Name:KAWERAK INC
Entity Type:Organization
Organization Name:KAWERAK INC
Other - Org Name:JACOBS HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-443-5231
Mailing Address - Street 1:PO BOX 948
Mailing Address - Street 2:P.O. BOX 948
Mailing Address - City:NOME
Mailing Address - State:AK
Mailing Address - Zip Code:99762-0948
Mailing Address - Country:US
Mailing Address - Phone:907-443-8096
Mailing Address - Fax:907-443-2708
Practice Address - Street 1:407 K STREET
Practice Address - Street 2:
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762
Practice Address - Country:US
Practice Address - Phone:907-443-8096
Practice Address - Fax:907-443-2708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK400297322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKBR0022Medicare ID - Type UnspecifiedBEAVHIORAL REAHBILITATIVE