Provider Demographics
NPI:1679796528
Name:COOK INLET COUNCIL ON ALCOHOL AND DRUG ABUSE
Entity Type:Organization
Organization Name:COOK INLET COUNCIL ON ALCOHOL AND DRUG ABUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:907-283-3658
Mailing Address - Street 1:PO BOX 882
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-0882
Mailing Address - Country:US
Mailing Address - Phone:907-283-3658
Mailing Address - Fax:907-283-5046
Practice Address - Street 1:126 W PIONEER AVE STE 11
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7564
Practice Address - Country:US
Practice Address - Phone:907-235-8001
Practice Address - Fax:907-235-8099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDA8820Medicaid