Provider Demographics
NPI:1629406749
Name:MAINSL ALASKA LLC
Entity Type:Organization
Organization Name:MAINSL ALASKA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DORETTA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:KOENIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-416-9102
Mailing Address - Street 1:7000 78TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-2744
Mailing Address - Country:US
Mailing Address - Phone:763-494-4553
Mailing Address - Fax:
Practice Address - Street 1:2029 CANNONEER CIR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-4697
Practice Address - Country:US
Practice Address - Phone:763-494-4553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health