Provider Demographics
NPI:1669636866
Name:CITY OF GALENA
Entity Type:Organization
Organization Name:CITY OF GALENA
Other - Org Name:EDGAR NOLLNER HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:DESANTO
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:907-656-2366
Mailing Address - Street 1:77 ANTOSKI AVENUE
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:AK
Mailing Address - Zip Code:99741-0077
Mailing Address - Country:US
Mailing Address - Phone:907-656-2366
Mailing Address - Fax:907-656-1525
Practice Address - Street 1:148 KATIDO STREET
Practice Address - Street 2:
Practice Address - City:KALTAG
Practice Address - State:AK
Practice Address - Zip Code:99748-0148
Practice Address - Country:US
Practice Address - Phone:907-534-2209
Practice Address - Fax:907-534-2216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCL4429Medicaid